The Sehatmandi programme is the backbone of Afghanistan’s health system, providing care for millions of people through 2,331 health facilities. Since the Taliban gained power, major funding for the programme has been withdrawn.
Without adequate funding, Sehatmandi health facilities are breaking down, affecting the availability of basic and lifesaving health care nationwide, as well as humanitarian assistance, polio eradication and COVID-19 vaccination efforts.
The Sehatmandi programme, if fully funded, will continue to provide essential and life-saving care to all Afghans. The hard-fought gains made in life expectancy, and maternal and child mortality over the past two decades will be kept.
Afghanistan’s health system is on the brink of collapse, and WHO is calling on international donors to rapidly finance the Sehatmandi programme, as they have done for almost two decades.
“We need to find innovative approaches to help millions of people including children, women and men in Afghanistan during this complex humanitarian crisis that is exacerbated by the COVID-19 pandemic and the on-going severe drought, combined with severe economic downturn. It is urgent, and the international community has a responsibility to act now.”
“The recent funding pause by key donors to the country's biggest health programme (Sehatmandi) will cause the majority of the public health facilities to close. As a result, more mothers, infants and children will die of reduced access to essential health care. WHO is determined to work with partners in identifying a sustainable solution with the support of donors to maintain and scale up the lifesaving interventions when needed in the country.”
“Bringing together in one package, health, clinical and surgical interventions, population public health interventions and inter-sectoral policy interventions, will go a long way towards helping improve the health of all Afghans. Sound and efficient implementation of the whole package will also help make the health system even more resilient, especially to disease [outbreaks] and injury shocks, and will also contribute to having a more responsive and inclusive health system.”
THE LONG READ
Ayesha, 29, is a midwife in a rural health facility in Afghanistan. She graduated from the provincial midwifery school supported by the government’s Sehatmandi programme, which provides essential primary care services including for maternal, newborn and child health. These vital health services that save the lives of many in the community have come under severe threat.
“I was born in a very remote district where health facilities were not available. I witnessed many pregnant mothers dying because there was no health care facility at my village or on the way to hospitals, located more than 50 km away. I decided to become a midwife and serve the women and children in the villages. I love my job and attend numerous institutional deliveries, and have contributed to the reduction of maternal mortality,” said Ayesha.
The primary care facility in the village is vital, serving 58,000 people including 13,340 women of childbearing age and 11,600 children under-five. Importantly, it provides emergency obstetric care, including Caesarean section services. Without this, women would have to travel far, and put themselves and their babies at risk.
Due to a lack of funding, staff in the health facility have not received their salaries for months, the clinic is faced with shortages of medicine and supplies, and patients are not able to access the essential health services they need. If this facility closes down, increasing ill health and mortality is inevitable. The facility’s struggles are not unique. The situation is replicated across the country because the Sehatmandi programme is no longer able to receive appropriate financial support due to the change in Afghanistan’s government. Previously funded by the World Bank, the European Commission, and USAID, there are now serious challenges to continuing these vital primary health care services. As of 15 January 2022, the country has received funding to help cover immediate needs for the early part of the year. More funds are needed to urgently fill remaining gaps and to support the country’s heath system in sustaining the delivery of essential services.
The population is also suffering due to a recent drought that has affected crops and livestock. This, combined with rising food prices and the collapse of public services, led to acute food insecurity for nearly 19 million people in September and October 2021.
The Sehatmandi programme
The Sehatmandi programme is the backbone of Afghanistan’s health system. It provides affordable health care for millions of people through 2,331 health facilities in 34 provinces, covering 64% of all public health facilities. The programme employs more than 24,000 health workers, of which 8,000 are women.
The Sehatmandi programme originated as the System Enhancement for Health Action in Transition (SEHAT) Project from 2013-2018, and transformed into the Sehatmandi programme in 2018. Equity principles have been central in this approach, allowing harmonization across the entire country with the aim of increasing health service coverage, especially for rural populations.
Because of a funding pause, most of the Sehatmandi health facilities are not fully functional and have stock-outs of essential medicines. The breakdown in health facilities is affecting the availability of basic and essential health services, as well as humanitarian assistance, polio eradication and COVID-19 vaccination efforts.
“I visited the public health facility to receive treatment but due to the shortage of medicines in the clinic, I didn’t get the proper medication. Unfortunately, many patients are disappointed because of the scarcity of medicines and supplies,” said Nasima, 32, a housewife in another Province.
For two decades in Afghanistan, life expectancy has risen, and maternal, newborn and child deaths have dramatically decreased. Today, the population’s health is seriously under threat. All the progress in health outcomes may be lost. WHO is urgently calling for international donors to step up and find an alternative funding mechanism for this crucial primary health care initiative.
BACKGROUND ON AFGHANISTAN
Two decades of progress in Afghanistan
In 2001, Afghanistan began to reform its health system. Over the past two decades, coverage of basic health services to its population had increased from 12% to 90%. In early 2003, the Ministry of Public Health introduced a Basic Package of Health Services, focusing mainly on improving maternal and child health. Equity was the guiding principle in the design and implementation of this effort.
In 2005, the Ministry also established an Essential Package of Health Services, which was a standardized package of hospital services with a referral system integrated with the Basic Package of Health Services. In 31 provinces these packages were delivered by non-governmental organizations, through a competitive bidding process steered by the Ministry of Public Health, and in 3 provinces through a mechanism enhanced by the Ministry.
“Bringing together in one package, health, clinical and surgical interventions, population public health interventions and inter-sectoral policy interventions, will go a long way towards helping improve the health of all Afghans. Sound and efficient implementation of the whole package will also help make the health system even more resilient, especially to disease [outbreaks] and injury shocks, and will also contribute to having a more responsive and inclusive health system,” said Feroz Ferozuddin, former Minister of Public Health (June 2019).
The health system, supported by these two packages, was resilient enough to cope with a range of political and economic instabilities. The population experienced reduction in morbidity and mortality, and substantial improvements in infant, child and maternal health. For example maternal mortality significantly dropped from 1,600 deaths per 100,00 live births in 2002 to 638 per 100,000 live births in 2020. Life expectancy at birth rose from 44.5 in 2004 to 63 in 2020. The number of functional health facilities increased from 498 in 2002 to 3,732 in 2020.
The key reasons for the success of these efforts were strong national stewardship, sound and stable policy frameworks, investments in primary health care, the introduction of the Basic Package of Health Services and Essential Package of Health Services, and significant and sustainable financial support from donors. At the start of 2021, before the change of government, Afghanistan was looking to expand services and integrate these two packages into an Integrated Package of Essential Health Services.
Urgent need to address the funding deficit
The Sehatmandi programme has been funded by the World Bank, the European Commission, and USAID through the Afghanistan Reconstruction Fund, managed by the World Bank. WHO, through the UHC Partnership, has provided, among other things, technical assistance to the Ministry of Public Health in a range of areas. This included a review of the health system, consultations to prepare a roadmap for moving towards universal health coverage in an emergency context, supporting the updating of a national essential package of quality health services and a mechanism for prioritization within the emergency context.
In August 2021, when the Taliban took over Kabul, donors found it impossible to provide financing through the new regime, and major funding was withdrawn. It is now increasingly urgent to find alternative approaches to fund the Sehatmandi programme.
“The recent funding pause by key donors to the country’s biggest health programme (Sehatmandi) will cause the majority of the public health facilities to close. As a result, more mothers, infants and children will die of reduced access to essential health care. WHO is determined to work with partners in identifying a sustainable solution with the support of donors to maintain and scale up the lifesaving interventions when needed in the country,” said Dr Luo Dapeng, WHO Representative in Afghanistan.
Lives at risk
The situation is already negatively affecting the health and lives of millions of Afghans. For example, under the Sehatmandi programme, on a daily basis in 2020, about 177 caesarean sections were performed and 516 major surgeries took place, of which 50% were emergency cases. As health centres close, over 4,000 children daily will be deprived from routine immunization services and over 19,000 children daily will be deprived from nutritional services. Family planning, maternal vaccination, anti-tuberculosis interventions and control and treatment of malaria will also be affected by the discontinuation of the Sehatmandi programme.
The COVID-19 pandemic has not yet been contained and the danger of subsequent waves is imminent. As of 2 December 2021, Afghanistan has reported 157,387 COVID-19 cases with 7,310 deaths. Overall, over 4 million people, or about 11% of the total population, have been vaccinated.
It is likely that all the health services provided under the Sehatmandi programme, including the provision of COVID-19 vaccine, surveillance and treatment services, will be suspended. The polio eradication programme, despite being funded vertically and not facing financial cuts, will lose its routine vaccination process if health facilities are closed down.
The experience of the last two decades shows that the network of primary health care facilities is at the core of preparedness and response to emergencies. Closing these facilities will reduce the response capacity to a minimum and will increase the risk of deaths.
Call to action to fund the Sehatmandi programme
WHO is now urgently calling for an alternative funding mechanism to support the continuation of health service delivery to the population. In September 2021, Dr Tedros Adhanom Ghebreyesus, Director-General of WHO, and Dr Ahmed Al Mandhari, Regional Director for the WHO Eastern Mediterranean Region, visited Kabul to discuss the situation and mobilize support. On average, the Sehatmandi programme costs about 180 million USD per year, or approximately US$ 15 million per month.
“We need to find innovative approaches to help millions of people including children, women and men in Afghanistan during this complex humanitarian crisis that is exacerbated by the COVID-19 pandemic and the on-going severe drought, combined with severe economic downturn. It is urgent, and the international community has a responsibility to act now,” said Dr Suraya Dalil, Director of the WHO’s Department of Special Programme on Primary Health Care.
WHO has 9 offices in Afghanistan, including a Country Office in Kabul and 8 Sub-offices in Badakhshan, Balkh, Bamayan, Herat, Kandahar, Kunduz, Nangarhar, and Paktia. WHO, through the UHC Partnership, is currently providing technical support for the implementation and revision of the Basic Package of Health Services and Essential Package of Health Services in the context of redesigning the Sehatmandi programme, beyond June 2021.
However, the Sehatmandi programme remains severely compromised without adequate and sustainable funding. While it may be challenging to find alternative and innovative ways to support the Sehatmandi programme, it is essential for the health and lives of the population of one of the poorest countries in the world and for health security globally.
Afghanistan is among the 115 countries and areas to which the UHC Partnership helps deliver WHO support and technical expertise in advancing primary health care (PHC) and universal health coverage (UHC). The Partnership is one of WHO’s largest initiatives on international cooperation for UHC and PHC. It is funded by the European Union (EU), the Grand Duchy of Luxembourg, Irish Aid, the Government of Japan, the French Ministry for Europe and Foreign Affairs, the United Kingdom – Foreign, Commonwealth & Development Office, Belgium, Canada and Germany.
Strengthening health security in Afghanistan
Despite the many challenges faced by the country, Afghanistan has shown its commitment and dedication to pandemic preparedness and to improving the quality and efficiency of its health care system by strengthening the implementation of the International Health Regulations (IHR 2005). At the end of 2016, the country organized and successfully conducted the Joint External Evaluation. The gaps identified by this process were then translated in the Afghanistan National Action Plan for Health Security which was completed in 2018. Since then, Afghanistan also conducted a Simulation Exercise in 2019 to assess and test the functional capabilities of its emergency systems, procedures, and mechanisms. Furthermore, in 2018, 2019 and 2020, Afghanistan submitted a review of its preparedness capacities through the State Party Self-Assessment Annual Reporting Tool, which consists of 24 indicators needed to detect, assess, notify, report and respond to public health risks of domestic and international concern.