The need to sustain funding for Afghanistan health system to prevent excess morbidity and mortality.

Background: The Afghanistan Reconstruction Trust Fund, managed by the World Bank through a contracted-out instrument called Sehatmandi, financed health service delivery in Afghanistan, with substantial achievements in infant, child and maternal health. After the collapse of the Afghan Government on 15 August 2021, the health system has been on the brink of collapse. Aims: We assessed the use of basic health services and estimated excess mortality resulting from the interruption to healthcare funding. Methods: We conducted a cross-sectional study that compared health services utilization from June to September for 3 consecutive years, 2019, 2020 and 2021, using 11 output indicators reported by the health management and information system. We used the Lives Saved Tool, a linear mathematical model with input data from the Afghanistan Demographic Health Survey 2015, to calculate the additional maternal, neonatal and child mortality at 25%, 50%, 75% and 95% reduction in health coverage. Results: During August and September 2021, after the announced ban on financing, health service utilization decreased to a range of 7-59%. Family planning, major surgeries and postnatal care showed the greatest decreases. Uptake of child immunization showed one-third decrease. Sehatmandi provides around 75% of primary and secondary health services: pausing funds to this programme will result in additional 2862 maternal deaths, 15 741 neonatal deaths, 30 519 child deaths, and 4057 stillbirths. Conclusion: Sustaining the current level of health services delivery is crucial to avoid excess, preventable morbidity and mortality in Afghanistan.

Analysis of human resources for health in Afghanistan.

Background: Despite large-scale investment in health service delivery outsourcing, few studies have examined human resources for health (HRH) in Afghanistan. Aims: To review the HRH situation of outsourced healthcare services in Afghanistan and evaluate nongovernment organization (NGO) investments in the health workforce. Methods: Two questionnaires were used for data collection. One gathered information about the characteristics of HRH in 2020 and the other collected budgetary data for 2017-2020 to analyse budget allocation and expenditure by NGOs on the health workforce. Results: A total of 25 262 (65% male, 35% female) individuals were employed by NGOs in 31 provinces of Afghanistan. There was a critical shortage of personnel and a prevalence of gender imbalance across all provinces. Healthcare workers were mostly aged 26 to 30 years. Services were mostly provided by local NGOs and their scopes were not limited to outsourced projects. More than 75% of the budget of NGOs was allocated to the health workforce in 2017-2020, and more than 70% of allocations was spent on staff salaries, followed by other health workforce expenditure. Less than 5% was spent on capacity building. Conclusion: There is a gross shortage and large gender imbalance in the Afghanistan health workforce. It is essential to maintain and increase current financial and technical investments to ensure sustainability and enhance the fragile health system in Afghanistan.

Global Fund financing and human resources for health investments in the Eastern Mediterranean Region.

BACKGROUND: Despite the large investments in donor-related health activities in areas of the globe prone to tension and conflict, few studies have examined in detail the role of these donor investments in human resources for health (HRH). METHODS: We used a mixed-methods research methodology comprising both quantitative and qualitative analyses to analyze the Enhanced Financial Reporting System of the Global Fund to Fight AIDS, Tuberculosis and Malaria budget and expenditure data from 2003 to 2017 for 13 countries in the Eastern Mediterranean Region (EMR). We analyzed additional detailed budgetary data over the period 2015-2017 for a sub-set of these countries. Two country-case studies were conducted in Afghanistan and Sudan for a more in-depth understanding of the HRH-related activities that occurred as a result of Global Fund grants. RESULTS: The results show that US$2.2 billion Global Fund dollars had been budgeted and US$1.6 billion were expended over the period 2003-2017 in 13 Eastern Mediterranean countries. The average expenditures for human resources for health (training and human resources) as a percentage of total expenditure are 28%. Additional detailed budgetary data analysis shows a more conservative investment in HRH with 13% of total budgets allocated to "direct" HRH activities such as salaries, training costs, and technical assistance. HRH-related activities supported by the Global Fund in Afghanistan and Sudan were similar, including pre-service and in-services training, hiring of program coordinators and staff, and top-ups for clinical staff. CONCLUSIONS: HRH remains a key issue in strengthening the health systems of low- and middle-income countries. While this study suggests that Global Fund's HRH investments in the EMR are not lagging behind the global average, there appears to be a need to further scale up these investments considering this region's unique HRH challenges.