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Economic Sustainability of Health Services


Afghanistan is a landlocked country located in South Asia; and is considered as a low income country. The economy of Afghanistan started to drastically decline after Soviet Union invaded the country in the late 1970s. Besides other systems of the country, the health system of Afghanistan has also drastically damaged during the decades of conflict. After the fall of Taliban in 2001, the international agencies strived to engage in the reconstruction of Afghanistan both technically and financially at different levels. The health system of the country attracted the attention of different donor agencies and technical partners to reconstruct the health system including, services improvement, human resources development, and financial assistance. The focus of this paper is to analyze economic sustainability of the health projects particularly Basic Package of Health Services (BPHS) and Community Health Nursing Education (CHNE) and Community Midwifery Education (CME) Programs in Afghanistan.

Search strategy

The supportive data in this paper have been retrieved from World Health Organization (WHO), World Bank (WB), Afghanistan’s Ministry of Public Health (MoPH) reports, searched from Google and Google Scholar. Search terms were conducted in combination of the keywords including; health, expenditure, GDP, NHA, public, private, out of pocket, BPHS, midwifery, nursing, cost, analysis, programs, and Afghanistan.


It is evident that the health system of Afghanistan is donor driven. The support to health by the donors come from two directions that is “On budget or Core budget” support which is channeled through the Ministry of Finance (MoF) and includes operating and developing budget which is fully supported by the donors and “Off budget” support which is directly transferred to the ministry of public health or service provider (Health Financing Policy-2012-2020, MoPH, 2011). To analyze (Table 1), it indicates that 20.8 percent (almost four time more than the public expenditure) of the health financing relies on donors besides that the maximum financing source is out of pocket. It is expected that after the withdrawal of the donors from Afghanistan, the country is supposed to self-cover all 26.4 percent of the health expenditure that seems impossible due to the fact illustrated in (Table 2) which indicates low income and low share of public health expenditure compare to the private share. The maximum external support is allocated to the two important health projects which are Basic Package of Health Services and community midwifery and community health nursing education programs.

Basic Package of Health Services

One of the main components of health services in Afghanistan is Basic Package of Health Services (BPHS) developed in 2003 to address priority health problems and provide standardized basic services to all Afghans in primary health care facilities (BPHS, 2009). In fact BPHS contributed enormous improvements in the health of the Afghan population in terms of coverage, quality, and accessibility during the last years. BPHS is delivered in the Health Posts, Health Sub-Centers, Basic Health Centers, Mobile Health Teams, Comprehensive Health Centers, and District Hospitals that significantly contributes in declining maternal and child mortality rate (BPHS, 2010).

Although BPHS have been playing a vital role in the well-being of the Afghan rural community, its financial sustainability is a real challenge after the upcoming expected withdrawal of the international donors and agencies from the country. BPHS was entirely supported by the external budget through European Union (EU) and USAID during 2008-2009 while World Bank (WB) assisted in development budget (NHA, 2011). The (Table 3 attached as annex) illustrates each donor’s contribution share to BPHS. As mentioned BPHS is entirely donor supported project, that carries 42.7 % of the total support of ($190,710,856) provided to the health system by different donors [NHA, 2011](Kindly refer to Table 5 for detail of total support to Afghan health system attached as annex). This percentage constitutes highest of the donor contribution to health sector which is a real challenge for MoPH to sustain on public health expenditure of 1.5% of GDP [WB, 2011] (Table 2).

Community Midwifery and Community Nursing Education

The second project of the MoPH i.e. nursing and midwifery education programs, is also donor supported. The MoPH has 34 midwifery programs in overall Afghanistan (kindly refer to Table 6 for more detail attached as annex) which are technically and financially supported by the NGOs and donors respectively. Beside this, CHNE programs have also started recently in different provinces of Afghanistan. Each CME and CHNE graduates an average of 25 students in a year. The (Table 4 attached as annex) expresses that around 3,283 midwives have been graduated from 34 midwifery schools that are supported by different donors (AMNEAB, 2011). According to HSSP (2010), the mean cost of training a midwife is estimated to be $13,206 per graduate student. This cost includes housing, food, training material, and others for the total of 26 months training program in Afghanistan. This figure indicates that an estimated total amount of $43,355,298 from 2002 (or in other word 25 students per batch X 34 schools X $6,603 in a year = $5,612,550 per year) has been contributed for the training of midwives which have positively contributed in the country’s health indicators. However, this is another burden on MoPH to sustain after the withdrawal of the donors from the country.

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According to the Tokyo conference on Afghanistan report (2012) that although the country GDP has increased from 7.5 % in 2008 to 11% in 2011, still the government is dependent on donor support. Moreover, even though there is grow of 140% increase in domestic revenue, the government expenditure has increased by 30% during the past three year from 2012 (Tokyo conference on Afghanistan, 8 July 2012). Therefore, it is vital to design programs to overcome this challenge.


Afghanistan ranks last among the eight South Asian region economies. Therefore, it is pivotal to the government to enhance national GDP through different means including agriculture, mines, trade, industries, and above all provide security for investment to enhance the economy of the country and become self-sustained. The MoPH has to negotiate with the MoF for the allocation of appropriate budget for health, which is a basic need and a vital component for a healthy and productive nation. Furthermore, it has been cited by Friedman and Liang (2011) that International Finance Corporation estimated the initial cost of a nursing or midwifery school to range from $0.3 to $2 million, and distance learning programs for nurses range from $0.2 to $0.5 million. Therefore, MoPH should strive to design programs and liaise with the international accredited midwifery and nursing schools particularly neighboring countries for distance learning to cut off the cost and make the education programs sustainable.


We conclude that BPHS and nursing and midwifery education programs in Afghanistan are donor driven and constitutes a yearly $87,026,327 (refer to Table 3 and Table 4 for detail) which is awkward for MoPH to cover and sustain the programs on its own expense of 1.5% of allocated GDP. Therefore, MoPH has to design exit strategies from external aid. The health financing policy and strategy has to be relooked in coordination with other stakeholders to address the demand.


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