Prospects for financial sustainability of basic package of health services in Afghanistan

Date of Award


Document Type


Degree Name

Master of Science in Health Policy & Management (MSc Health Policy & Mgmt)


Community Health Sciences


Abstract: Background: In 2002 Afghanistan government developed a Basic Package of Health Services (BPHS) as a strategy to reform the health sector. The BPHS is based on the health sector priority and includes four levels of facilities; Health Posts (HPs), Basic Health Centers (BHCs), Comprehensive Health Centers (CHCs), and District Hospitals (DHs) which covers more than 85% of the country. The BPHS has been contracted out to the Non-for-Profit Organizations through a competitive process. In addition the MoPH is running the BPHS in three provinces called "Strengthening Mechanism" (MoPH-SM). Rationale: The package is financially supported almost all by external assistance whose long term commitment is questionable. Meanwhile, the Constitution of Afghanistan is against the cost sharing and user fee systems in the public health facilities, though a user fee project for health services was piloted in some provinces with positive results. The above information indicated that the financial sustainability of BPHS is questionable and donor dependency has become a concern of many citizens of Afghanistan hence important to be addressed. Methodology: A mixed method research to examine these concerns objectively. A desk review conducted to analyze the BPHS financial data. A qualitative approach using interview of stakeholders conducted to explore their perceptions, interest, power and position about establishment of a financially sustainable mechanism. It also explored the impact on the stakeholders when the donors' funding to BPHS is withdrawn. Result: The external aid to health sector increased 4.5 times while there is only 1.5 times increase in Government allocation to health sector during past five years (2005-2009). It is found that 99% versus 1% of BPHS funding sources are donor agencies and domestic revenues respectively. The funds committed by donors to BPHS show a significant reduction in real term during the past five years and next four years (2005-2013). The study also revealed a variation of cost per capita among donors' funding to BPHS. The stakeholder analysis revealed a high interest, very supportive position but low power of the Ministry of Public Health; high power, but low interest and non-mobilized position of Ministry of Finance; relatively supportive position of politicians; high power but low interest and non-mobilized position of the development partners, medium interest but low power and non-mobilized position of NGOs; high interest, supportive position but low power of the community to the financial sustainability of BPI-IS. It also revealed that the higher impact will remain with the community and NGOs respectively if the donors stop funding. Conclusion: The BPHS is almost reliance on the external aid, and stakeholders are suboptimally organized to come up with effective alternatives to finance it. The MoPH should initiate a prompt policy dialogue to work on an exit strategy for external aid and assess the sources and extent of financing the BPHS, so that it could come up with a decision on whether the modifications to the existing BPHS are needed.

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