Moving toward UHC Afghanistan NATIONAL I N I T I AT I V ES, KEY CHALLENGES, AND THE ROLE OF COLLABORATIVE ACTIVITIES Moving toward UHC: Afghanistan Afghanistan’s snapshot 1 Afghanistan’s snapshot Existing national plans and policies to achieve UHC 2 31+69+C Key challenges on the way to UHC 4 UHC Service Coverage Results of Joint External Evaluation Collaborative efforts to accelerate progress toward UHC 6 Index (SDG 3.8.1, 2015) of core capacities for pandemic preparedness (JEE, 2016) 31% References and definitions 8 Score (for capacity) # of indicators (out of 48) 5 Sustainable 0 4 Demonstrated 8 Catastrophic OOP health expenditure incidence at the 10% threshold 3 Developed 2 (SDG 3.8.2, 2007) 2 Limited 19 4.8% of households 1 No capacity 19 Health results Performance of service delivery – selected indicators LMIC Maternal Mortality Under-Five Mortality (PHCPI, 2014-2015) Afghanistan average Ratio (WHO) Rate (WHO) Per 100,000 Live Births Per 1,000 Live Births Care-seeking for symptoms of pneumonia 61.5% 61.5% 1340 Dropout rate between 1st and 3rd DTP vaccination 11% 7.5% 396 181 Access barriers due to 91 treatment costs 66.7% 47.4% Access barriers due to distance 67.2% 35.8% 1990 2015 1990 2015 70 (SDG target) 25 (SDG target) Treatment success rate for new TB cases 87% 80.1% Life Expectancy Wealth Differential at Birth (WHO) in Under-Five Mortality (PHCPI, 2015) Provider absence rate NO DATA 28.9% Caseload per provider NO DATA 9 31.5 per day 61 55 Diagnostic accuracy NO DATA 47.9% More deaths in lowest than highest wealth quintile Adherence to 2000 2015 per 1,000 live births clinical guidelines NO DATA 33.6% See page 8 for References and Definitions. 1 Moving toward UHC: Afghanistan Moving toward UHC: Afghanistan Existing national plans and policies to achieve universal health coverage (UHC) SERVICE DELIVERY REFORMS antenatal care (UNICEF) and increase the Delivering a free universal package of health uptake of childhood vaccinations (Gavi). In services. The Afghanistan government, in some areas, mini-ambulances (“Zaranj”) run by its 2016–2020 Health Strategy, committed to community health workers improve the referral achieving universal health coverage (UHC) by and transportation of maternal, newborn and providing basic quality health services and child health patients (UNICEF). The challenge hospital services to its entire population. To remains to further incentivize local innovation achieve this goal, the June 2017 Afghanistan and to scale up those that have been found to Health Presidential Summit set strategies to: be cost-effective, affordable and acceptable (a) increase accountability to communities; across a wider population. (b) shift from contract management to performance management; (c) increase HEALTH FINANCING REFORMS efficiency in service delivery; (d) encourage Establishment of the “2012–2020 Health health management innovations; (e) address Financing Policy.” The Ministry of Public emerging challenges in hospitals, health Health (MoPH) set out a new policy to increase financing, and pharmaceuticals; and (f) improve total financing for the health system. This communications with all stakeholders. aims to identify ways to mobilize domestic resources through taxation and prepayment Piloting NGO innovations. Nongovernmental mechanisms, increase efficiency and equity in organizations (NGOs) play a large role in the public spending through different financial provision of health services in Afghanistan mechanisms, improve risk pooling through due to unique contracting arrangements. health financing schemes, secure more Innovations in service delivery by NGOs sustainable external funding, and enhance aid remain small scale, and include conditional effectiveness for existing health priorities. cash transfers to encourage women to utilize GOVERNANCE REFORMS Engagement of non-state actors in service Improved coordination and oversight. The delivery. The Afghanistan government MoPH engages with technical departments established a regulatory framework for and provincial health offices in the design, The Afghanistan government established a regulatory community engagement in service delivery recruitment, and oversight of contracts for though the Citizens Charter, providing delivering the basic package of health services framework for community engagement in service delivery an opportunity for beneficiaries to collect (BPHS) and essential package of hospital through the Citizens Charter, providing an opportunity for performance data from over 2,000 facilities services (EPHS). There is a semiannual to complement existing monitoring data. performance review of contracts that involves beneficiaries to collect performance data from over 2,000 Health promotion campaigns aim to empower all relevant departments and capacity facilities to complement existing monitoring data. Community Development Councils to strengthening on data analytics. play a leading role in the improvement of their local facilities. 2 3 Moving toward UHC: Afghanistan Moving toward UHC: Afghanistan Key challenges on the way to UHC WEAKNESSES AND BOTTLENECKS communities, service delivery has generally IN SERVICE DELIVERY been resilient to ongoing conflicts. Coverage of essential health services. Afghanistan has made notable progress Pandemic preparedness. A 2016 Joint External in maternal, newborn, and child health, Evaluation (JEE) of International Health intervention coverage, and service availability. Regulations (IHR) core capacities identified From 2000 to 2015, maternal mortality, under-5 multiple important aspects of readiness mortality, and newborn mortality all declined; where Afghanistan currently has no capacity: coverage for antenatal care, key immunizations, national policy, legislation, and financing; IHR in-facility births, and skilled birth attendance coordination, communication, and advocacy; increased most rapidly from 2010–2015. Similar antimicrobial resistance; food safety; biosafety trends at the provincial level show service and biosecurity; points of entry; chemical coverage and health system improvements for events; and radiation emergencies. In contrast, THE STATE OF HEALTH FINANCING public budget is systematically below planned nearly all provinces. Despite these advances, Afghanistan has demonstrated capacity in Overall funding for health. Afghanistan has levels. Estimates from a fiscal space analysis health outcomes in Afghanistan are still among several other areas that only require additional one of the lowest expenditures per capita on sponsored by the MoPH show that increasing the worst in low-income countries. Neonatal efforts to ensure these capacities are sustainable. health in the region; this is even worse when the execution rate of the total government mortality and nutritional deficiencies in These areas include zoonotic diseases; national comparing the proportion of government budget to 86% could generate an additional children remain pressing issues. However, due vaccine access and delivery; laboratory testing spending. According to the 2014 National US$7.2 million per year over the period of to existing contract arrangements with NGOs for identification of priority diseases; real-time Health Accounts, 72% of health expenditures 2017–2021, representing an increase of 3% and private entities for the provision of health surveillance; and linking public health and come from out-of-pocket (OOP) spending; 23% per year. Potential areas for fiscal space gains services, many of which have close ties to local security authorities. from external aid; and only 5% from the central include hospital autonomy, procurement, task government. The main challenges for the shifting, and investments in preventive care. government in health financing are: (i) increase domestic financing for UHC; (ii) increase GOVERNANCE CHALLENGES efficiency in the execution of the public budget; War and conflict. Armed conflict in and (iii) reduce high out-of-pocket (OOP) Afghanistan has intensified since 2010, expenditures. Advocacy is needed to improve and an increasing share of the population the regulatory environment for domestic lives in areas affected by high levels of resource allocation to the health sector. In conflict. Maintaining health service delivery In high-conflict provinces, contracting out to addition, dependence on external donor funds and responding to health needs remain NGOs has supported resilience in service delivery, for the delivery of health services financed key challenges, with health facilities in through competing mechanisms with limited low-conflict provinces able to achieve as many contractors retain close ties to, and hire coordination must be reviewed, especially in better coverage. In high-conflict provinces, directly from, local communities. contexts where external funds for health could contracting out to NGOs occurs at the same become scarce. frequency, supporting some resilience in service delivery as many contractors Efficiency in the use of the public funding. retain close ties to, and hire directly from, Analyses indicate that the execution rate of the local communities. 4 5 Moving toward UHC: Afghanistan Moving toward UHC: Afghanistan Collaborative efforts to accelerate progress toward UHC EXISTING INITIATIVES SUPPORTED the Global Fund and Gavi, to contribute to BY EXTERNAL PARTNERS health system strengthening. Considering External partners are engaged in Afghanistan that other sectors, such as nutrition and water to build national capacity and strengthen the and sanitation compose the foundations health system. The Tokyo Joint UHC Initiative, of heath for all, challenges in these fields also supported by the government of Japan and led will be considered under the joint work. by the World Bank (WB), in collaboration with the Japan International Cooperation Agency Other planned activities (JICA), the United Nations Children’s Fund Technical assistance to the MoPH will support (UNICEF), and the World Health Organization analytical work to produce information for (WHO), is supporting the government of policy decisions regarding: (a) increasing and Afghanistan, and strives to accelerate progress sustaining financing to improve government toward UHC. This support will enable awareness of investment opportunities for strengthening of nationally-led strategic health health; (b) analyzing of the Public Spending systems to achieve UHC, as well as pandemic Budget Efficiency to define strategies to preparedness. increase efficiency in the use of the public budget and reduce the gap between initial PLANS FOR FUTURE allocations and final spending; and (c) COLLABORATIVE WORK analyzing of OOP spending in search of policies to reduce OOP spending or improve Policy and Human Resources Development efficiency in the allocation of these resources. (PHRD)-funded advisory support The joint work under the Tokyo Joint UHC The PHRD activities are very closely tied to Initiative falls within four major areas: the new IDA18 financing for health as the improving performance management, new operation is very much focused upon strengthening the health system, increasing and the same areas of improving performance sustaining health financing, and community management, community-based services, engagement. Efforts to improve performance and pandemic preparedness, and achieving management will include a functional review greater financial sustainability. The PHRD of the Ministry of Public Health; a review and funding therefore will increase the quality revision of the monitoring and accountability of implementation support and potentially framework; and a performance review of impact current and future lending by focusing essential primary health service contracts, of on areas that are complementary. This demographic and health surveys, and provincial also strengthens partnerships with other hospitals. Furthermore, the Tokyo UHC institutions, thereby increasing the impact joint work will closely cooperate with other of lending through harmonizing the work of investments in health, such as those by different donors. 6 7 Moving toward UHC: Afghanistan References & Definitions (page 1 indicators) UHC Service Coverage Index (2015) – Life Expectancy at Birth (2000-2015), WHO/World Bank index that combines 16 Maternal Mortality Ratio (1990-2015), tracer indicators into a single, composite Under-five Mortality Rate (1990-2015) – metric of the coverage of essential health WHO Global Health Observatory: services. For more information: WHO/World http://apps.who.int/gho/data/node.home Bank (2017). Tracking UHC: Second Global Monitoring Report. Wealth Differential in Under-five Mortality (Single data point, year varies by country) Catastrophic out-of-pocket (OOP) health – Indicator used by the Primary Health Care expenditure incidence at the 10% threshold Performance Initiative (PHCPI) to reflect equity (Single data point, year varies by country) – in health outcomes. For more information: WHO/World Bank data from Tracking UHC: https://phcperformanceinitiative.org/indicator/ Second Global Monitoring Report (2017). equity-under-five-mortality-wealth-differential Catastrophic expenditure defined as annual household health expenditures greater than Performance of service delivery – selected 10% of annual household total expenditures. indicators (Single data points, years vary by country) – Indicators used by the Primary Health Results of the Joint External Evaluation of Care Performance Initiative (PHCPI) to capture core capacities for pandemic preparedness various aspects of service delivery performance. (2016/17, year varies by country) – A voluntary, PHCPI synthesizes new and existing data from collaborative assessment of capacities to validated and internationally comparable prevent, detect, and respond to public health sources. For definitions of individual indicators: threats under the International Health https://phcperformanceinitiative.org/about-us/ Regulations (2005) and the Global Health our-indicators#/ Security Agenda. 48 indicators of pandemic preparedness are scored using five levels (1 is no capacity, 5 is sustainable capacity). https://www.ghsagenda.org/assessments Photo credits: Page 3 & 5: Ishaq Anis / Rumi Consultancy / World Bank Page 7: Imal Hashemi / Taimani Films / World Bank Co-authored by: 8