Despite two decades of conflict and low domestic spending on health, Afghanistan has improved health outcomes in several key areas, including fewer deaths for both mothers in childbirth and children under five. Yet progress on maternal and neonatal mortality has slowed, with Afghan children continuing to suffer from chronic malnutrition. The Global Financing Facility (GFF) has worked with the Afghan government to transform its health service delivery model to help expand access to quality care in most of the country’s provinces while also improving efficiency and accountability. These changes have contributed to improvements in several core maternal and child health indicators, such as more attended births, improved access for women and girls to contraceptives, and increased antenatal and postnatal care.
Improving Health Outcomes Across the Country
In the face of a fragile political climate, Afghanistan has made notable progress in improving maternal and child health and nutrition as well as in strengthening service delivery. Between 2015 and 2018, mortality rates for children under five and newborns dropped sharply—by 35 percent and 34 percent respectively. In the same period, stunting declined from 40 to 36 percent and wasting dropped from 9.5 percent to 5 percent. Though these key indicators have improved, nearly a quarter of Afghan women report an unmet need for family planning, which points to a sluggish prevalence rate of modern contraceptives. In many provinces across the country, quality of services also remains a top concern.
Over the past two decades, Afghanistan’s health system has benefited from the support of multiple donors who have contributed to its substantial health progress. However, increasing the government’s budget for health—currently at 2.3 percent of the total budget—remains an issue.& As the country struggles with low revenue and a continued need for security-related expenses, Afghanistan’s out-of-pocket expenses have climbed to a staggering 75.5 percent of total health expenditures, among the highest in the world.
With domestic health spending likely to remain low for the foreseeable future, in 2018 the government initiated a major reform to expand quality services: contracting independent service providers—generally nongovernmental organizations (NGOs)—to deliver basic and essential health services in 31 of the country’s 34 provinces, where the government does not provide them. The reforms included strategic purchasing of services that pay providers based on good performance and hold providers accountable to quality standards. These new performance-managed contracts have been implemented since January 2019.
Aligning Partner Support around Priorities
Afghanistan’s first-ever investment case for women’s, children’s, and adolescent health aligns resources to address the country’s main health priorities. It is funded by the Afghanistan Sehatmandi Project, a US$600 million, three-year investment to improve the delivery and quality of health, nutrition, and family planning services in 34 provinces across the country. The project is co-financed by a US$35 million GFF catalytic grant linked to larger contributions from the World Bank’s International Development Association (US$140 million); the Afghanistan Reconstruction Trust Fund (US$425 million), which includes contributions from Canada; the European Union; and USAID, along with other bilateral partners.
Through its support to the project, the GFF has helped the government to strengthen accountability and efficiency in the health sector, while also nurturing a culture of data use to help inform decisions. A first-ever province-wide resource mapping and expenditure tracking exercise has revealed the impact of investments on basic health service quality. The exercise also identified funding gaps where \ align external resources could be better aligned around health priorities. The GFF has also supported the government and development partners as they scale existing innovations in health services, including the expansion of high-impact interventions to prevent post-partum hemorrhage, reduce the incidence of neonatal sepsis, and expand the range of available modern methods of contraception.
Improving Efficiency, Accountability, and Access to Services
The GFF assisted the Ministry of Public Health in transforming Afghanistan’s unique contract-based health service delivery system, where contracts are now selected through a competitive process. A portion of the payments are linked to performance on 11 key services, with the provider’s quality of service verified by an independent, third-party monitor. This major reform has enabled the Ministry of Public Health to play a stewardship role in monitoring both service quantity and quality. In addition, the performance-based payment system has spurred a more profound institutional transformation, with the Ministry establishing a new unit dedicated to overseeing these healthcare contracts.
By shifting how it manages contracts, the Afghan government has achieved remarkable gains in efficiency and accountability: Between 2018 and 2019, the ratio of health service providers subject to semi-annual reviews leaped from zero to 100 percent, which helped inform future contract decisions. As a result, the percentage of NGOs receiving timely payments surged from zero in 2018 to 73 percent in 2019.
More importantly, the new contract system, along with the Sehatmandi project, has propelled improvements in several major health areas, including increased access to services, more effective family planning, and improved maternal care. A few examples for each include:
Increased access to services:
- Since the Sehatmandi project launched, 25 percent more children under five have visited project-supported outpatient care facilities.
- Vaccinations administered to newborns in health facilities have risen 8 percent; however, five provinces have reported declines in vaccination rates.
- Growth monitoring for children under two and child feeding counseling—designed to help accelerate the reduction of stunting—was rolled out in all 34 provinces supported by the project. This has resulted in more than 5.6 million growth monitoring visits to project-supported facilities nationwide.
More effective family planning:
- The couple-years of protection (CYP)—which estimates the protection from pregnancy provided by contraceptive methods—increased by 55 percent in Sehatmandi-supported facilities across the country, with increases reported in 29 provinces.
Improved maternal care:
- Across the country, 32 percent more antenatal visits were recorded across the country, with only two provinces showing declines.
- Postnatal care visits increased by 36 percent at Sehatmandi-supported health facilities.
- Nationally, the total number of institutional deliveries increased by 30 percent. From a baseline of 2.5 percent in 2017, the number of cesarean sections rose by 63 percent to 3.2 percent—still short of the 10 percent benchmark identified by the World Health Organization (WHO) as supporting optimal mortality outcomes.
Currently, the GFF is working with the Government of Afghanistan to develop an expanded investment case that reaches beyond the Sehatmandi- supported program, to better align and coordinate between this program and health-related initiatives financed by other partners. By positioning a greater share of health resources around a common plan focused on high-impact interventions, and supporting national systems to enhance service quality, strategic purchasing, public financial management as well as data use and production, Afghanistan expects to continue building upon the progress experienced in recent years.