20 years of health system progress in Afghanistan: what now?

At the core of much human trouble, is that it so much easier to destroy than to create. The Taliban’s act of blowing up the Buddhas of Bamiyan in early 2001, symbolised the destructive nature of their whole regime which had already reversed centuries of development in Afghanistan.

As they reassume control of the country, immediate concerns are naturally for the numerous humanitarian emergencies and for the futures of women and girls in particular. It is also worth giving some thought to the twenty years’ worth of effort to build the health system since 2001, and what prospects there may be for retaining any of the gains made.

The health system attracted early attention in the aftermath of the US and British invasion of the country in late 2001. There was substantial investment in rebuilding a public health system associated with some of the worst health outcomes ever observed, in particular a maternal mortality ratio reaching 6507 per 100,000 live births in one province assessed; and reportedly averaging 1390 across the country in 2001 according to UNICEF data that also report contemporary rates of 88 infant deaths and 124 deaths of children under 5 per 1000 live births. (Other contemporary reports cite higher numbers and it is likely that data are as unreliable as the health system seems to have been). An early commentary indicates that public health infrastructure was virtually absent in rural areas and the gap partially filled by NGOs, but with a ratio of one functioning facility for 50,000 people.

Several innovations were implemented in the attempt to strengthen the Afghan health system after 2001, including the development of a basic package of health services, contracting NGO services to deliver that package and introducing new approaches to monitoring and evaluation of service provision.  A “balanced score card” (BSC) approach, that collected and used multiple perspectives on the performance of the system, was introduced. These innovations have generally been well regarded, and the period at least up to about the second decade post invasion, considered to have been one of progress. For example, rural access to the basic package of primary health care services was reported to have ‘increased dramatically’. The contracting out of service provision to non-state providers has been given much of the credit for this scale-up and for reducing inequities in access in the process. These conclusions have been significantly underpinned and supported by using the BSC approach. The most recent health indicators from the same UNICEF data set indicate that infant and child mortality have approximately halved and maternal mortality reduced by about two thirds, while the percentage of births occurring in institutional settings has increased more than four-fold from 12.9 in 2003 to 53.3 in 2018.

Of course, problems in accessing health care have persisted and there have been critics of the approaches used. An article in 2013 highlighted a range of concerns. Contracting processes have been the subject of controversy and the budget available for the basic service package at $4 per person per head, further eroded by price competition among contract bidders has been considered too low to support the costs of effective service coverage. The BSC has been considered ‘flawed in implementation’ and unreliable. The estimated rapid improvement in access has been challenged, and may not have related to packages of health services that would make a meaningful difference to health. Levels of use of the public system at about half of those that sought care, support an understanding that there remained significant barriers to access and remaining inequities in patterns of access. The status and capacity of the health workforce has been central to these concerns. The primary care package has substantially relied on community health workers, a program that has been highly constrained by gender inequalities. Increasingly, in the second post-invasion decade, insecurity has constrained progress.

Health system building has been proposed as a ‘bridge to peace’, and if it hasn’t worked out that way in Afghanistan, there are probably sufficient explanations in the previous paragraph. Additionally, the development of governance systems had not evolved to the point where Afghan institutions had regained sovereignty over the health system and the progress made – whether impressive or limited – was probably insufficiently credited to government stakeholders for increased confidence in those stakeholders to be translated into reduced support for the Taliban insurrection.

Given the extensive humanitarian crisis unfolding and considerable uncertainty about how the new Taliban regime will govern, it will probably take some time before the health system regains much international attention. Much of the determination of whether the toll of avoidable deaths among children and women regress to their 2001 levels will be shaped by whether the Taliban do indeed allow any increased measure of autonomy and dignity for women and girls.

The loss of international support will almost certainly ensure that the structures and systems painstakingly built and the hard achieved progress, however partial and imperfect, will be destroyed with the same ease as the Buddhas were. If the new regime does value its citizens’ health and their access to health care, there are assets on which to draw in the investments in infrastructure and the community health workforce. These are small seeds of hope, both of which will depreciate with neglect.

This article was written by Professor Barbara McPake, Director, Nossal Institute for Global Health,

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