The document discusses Afghanistan's health system challenges and a comprehensive approach to building a sustainable system. It outlines challenges like dependence on donors, high out-of-pocket costs, and low public spending. The proposed approach includes mobilizing local resources by training staff, gradually decreasing donor dependence through new revenue and improving budget execution, coordinating aid, and ensuring sustainability by transitioning donor-funded staff and improving salaries. The presentation reflects on designing a new system from scratch in post-conflict countries.

1. better systems, better health
Comprehensive Approach to
Building Afghanistan Health
Economics & Finance Directorate
Better Health Systems: Strategies that Work
Presentation Series at the Global Health Council
Ibrahim Shehata
February 7, 2012
Abt Associates Inc.
In collaboration with:
I Aga Khan Foundation I Bitrán y Asociados
I BRAC University I Broad Branch Associates
I Deloitte Consulting, LLP I Forum One Communications
I RTI International I Training Resources Group
I Tulane University’s School of Public Health

2. Summary
 Challenges
 Planning comprehensive approach
 Transitioning to self-sustaining health systems

3. Challenges
 Dependence on donor funding (85%) and no tax
base for revenue generation
 High level of OOP (75%)
 Limited capacity in budget execution (60%)
 Low public per capita expenditure (4%)
 Low capacity in applied health economics and
resource management

4. Planning for Comprehensive
Approach
 Develop a comprehensive health financing strategy
that emphasizes:
 Mobilizing Afghan human resources
 Gradual decrease on donor dependency
 Aid coordination
 Sustainability

5. Mobilize Local Resources
 Build and institutionalize
the technical capacity of
HEFD staff:
 Enrolled 7 HEFD staff in
master’s degree program
in health economics
 On-the-job training
programs provided to
HEFD staff
 HEFD organizational and
operational improvements

6. Gradual Decrease on Donor
Dependency
 Develop revenue generation policy that introduces
“sin taxes” on interventions having negative
externalities on health
 Support MOPH advocacy efforts
 Evaluate user fees
 Improve budget execution to 100%

7. Improve Aid Coordination
 Coordinate technical support with WB, EC, and other
USAID projects
 Expenditure management information system
 Health financing policy
 Costing BPHS, EPHS, and vertical programs

8. Ensure Sustainability
 Implement the most comprehensive public program to
transition donor funded civil servant employees into the
Afghan “tashkeel” (civil service system)
 Cost tashkeel positions
 Identifying staffing capacity needs currently missing in the tashkeel
 Both take stock of and cost the training, which will enable “topped up”
staffing positions to effectively and efficiently perform their functions
 Increasing competitiveness of tashkeel salaries
 Develop an action plan and timeline for the MoPH to implement
changes
 Design a five-year performance-assessment-monitoring and
evaluation process and reporting framework

9. Reflection
 In some ways, it is easier to impact health systems in
post-conflict countries because often you are
designing the system from scratch without having to
navigate the existing system and its bureaucracy

10. better systems, better health
Thank you
www.HealthSystems2020.org
Abt Associates Inc.
In collaboration with:
I Aga Khan Foundation I Bitrán y Asociados
I BRAC University I Broad Branch Associates
I Deloitte Consulting, LLP I Forum One Communications
I RTI International I Training Resources Group
I Tulane University’s School of Public Health