Afghanistan: Better Health Outcomes for Women, Children, and the Poor

Challenge

In 2003, Afghanistan was among the poorest countries in the world, emerging from decades of conflict and in the midst of post-conflict reconstruction and transition, with substantial international security and development support. 

Afghanistan’s health situation was also among the poorest in the world, with a lack of health coverage, prenatal care, vaccine coverage, and health facilities. Most rural infrastructure was either destroyed or in dilapidated condition. Service coverage was very limited and uneven. Many years of internal strife had heavily disrupted the public network of services and most health services were largely provided by nongovernmental organizations (NGOs) financed under humanitarian programs. These NGOs were financed directly by (and reported to) the external donors and not the government, and as a consequence there were large deficiencies and inequalities in infrastructure, human resources, and availability of services. Many rural areas had no modern health services at all. Some NGO programs were uncoordinated, without a common policy framework or technical standards.

Approach

The health sector’s main partners for financial support are the European Union (EU), the U.S. Agency for International Development (USAID) and the World Bank. Under leadership of the World Bank, these partners agreed with the Ministry of Public Health to finance the delivery of a well-defined basic package of health services (BPHS) and essential hospital services (EPHS). Their combined support covered all provinces. In the large majority of provinces, service delivery was still by NGOs under a contracting mechanism, while the ministry focused on developing capacity for its stewardship functions. This contracting mechanism was a very innovative move for Afghanistan. The contracts between the ministry and the NGOs were performance-based and the NGOs were given freedom to reach their targets using creative solutions adapted to local situations while keeping efficiency and effectiveness in mind.

When annual increases in service coverage started leveling off, the Bank introduced a results-based financing (RBF) approach as a further innovation. The results of the pilots are so far very promising with an ever-increasing difference between the intervention and control groups.

Results

Most of the beneficiaries of the health projects are women and children, who make up the most vulnerable part of the Afghan society and had the least access to care and the greatest health needs.

As a result, prenatal care coverage is now 39%, up from 6% in 2003, and institutional deliveries are now at 43%, up from 7% in 2004.

Maternal Health: The maternal mortality rate dropped from 1,600 per 100,000 births in 2000 to 327 in 2010. Contraceptive use has increased from 5.1% for rural areas in 2003 to 20% in 2011. The fertility rate has dropped by almost 20% from 6.3 in 2000 to 5.1 in 2010. Qualified delivery care in rural project areas increased six-fold-from 6% in 2003 to 31% in 2011. Nationwide, the improvement is from 14% in 2003 to 39% in 2010/11.

Child health: Under-5 mortality has dropped from 257 per 1,000 live births in 2002 to 97 per 1,000 in 2012. Full immunization coverage in rural areas tripled from 11% in 2003 to 30% in 2010/11.

The projects’ support to improved tuberculosis control is important in that the disease constitutes a very large burden in Afghanistan, and particularly affects the poorest. The treatment success rate rose from 80% reported in 2003 to 89% reported in 2008 and 2011.

Part of the projects’ success in improving health coverage involved support for substantial physical expansion of health services. Nationally, in 2002, the World Health Organization (WHO) estimated that 496 health facilities were delivering basic health services; there are now an estimated 2,047 health facilities across the country.

World Bank Group and ARTF Contribution

International Development Association (IDA) grants totaling $190 million through the Health Sector Emergency Construction and Development Project (2003-2009) and the Strengthening Health Activities for the Rural Poor Project (2009-2013) were co-financed by the Afghanistan Reconstruction Trust Fund (ARTF, $22 million), Japanese Social Development Fund (JSDF, $18 million), and Health Results Innovation Trust Fund (HRITF, $12 million).

The operational support was combined with analytical work to study and advise the government on key strategic matters regarding health financing. The results-based financing pilots are followed with a thorough impact evaluation. The Bank is also supporting the ministry in management of tertiary care through IDA.

Partners

The ministry’s main partners are the EU, USAID, and the World Bank. Over the years, these three partners have together financed most of the basic and secondary health care in the country through the ARTF. While the funding streams were in parallel, the ministry ensured that partners worked closely together to guarantee that the package of services is standardized across the country. For the new System Enhancement for Health Action in Transition (SEHAT) project, the EU funds will now be provided through the ARTF, thereby further harmonizing the funding stream to the sector.

Moving Forward

Afghanistan is now challenged to safeguard the enormous progress made in the sector over the last decade and build on this during the coming period of transition, when foreign security support will drastically diminish. The Ministry of Public Health must turn the emergency response into sustainable development by mainstreaming the structures set up under the emergency phase.

The basic package of services also needs to be expanded to address better the main health needs of the populations. Modules have been developed to address mental health and malnutrition.

The Bank’s Board recently approved the new System Enhancement for Health Action in Transition (SEHAT) project (2013-2018), supported by the ARTF ($270 million) IDA ($100 million), the HRITF ($8 million), and a $30 million government contribution.