Sehat-Sehatmandi Environmental and Social Management Framwork


Despite insecurity and unstable governance since 2001, Afghanistan has made notable progress in improving maternal, new-born, and child survival, nutrition, health interventions coverage and service availability to its population. The recent 2016 Demographic and Health Survey (DHS) shows a sharp reduction in under 5 mortality rate (U5MR) to 55 per 1,000 live births from 97 per 1000 live births in 2010. The large influx of financial assistance, strong local stewardship, development of sound and stable health policy frameworks, prioritization of investments in primary care and the introduction of a basic package of health services (BPHS) and essential package of hospital services (EPHS) delivered by non-governmental organizations (NGOs), have been among some of enablers of success. For the last 15 years, the European Union (EU), the United States Agency for International Development (USAID) and the World Bank have been supporting health service delivery in Afghanistan, initially each targeting a specific set of provinces. But under System Enhancement for Health Action in Transition (SEHAT) project 2013 - 2018 resources allocated for BPHS and EPHS (on and off -budget) came under one umbrella through Afghanistan Reconstruction Trust Fund (ARTF) platform covering the entire country. Therefore, SEHAT is a nation-wide project with similar procurement and implementation approach across different provinces, which is going to continue under the proposed Sehatmandi project.


The coverage of maternal, neonatal and child health services, the health outcomes remain sub-optimal in Afghanistan. Despite significant increases in skilled birth attendant deliveries maternal mortality ratio (MMR) remains very high, estimated to be 650 per 100,000 live births. Also, neo-natal mortality rates are persistently high, accounting for about 40 percent of the total under 5 mortality. The poor quality of care continues to hamper overall health improvements.


Given the socio-political environment, the demand side factors influencing preventive health care services and community engagement have been relatively underplayed in the past. As a result, critical interventions such as family planning and maternal and infant and young child nutrition related behaviours remain at low levels. With Government of Afghanistan’s effort in implementing an ambitious program to strengthen community engagement and empowerment through the Citizens’ Charter Afghanistan Program (CCAP), it offers an opportunity to scale up demand side interventions, and scale-up small-scale pilots, such as, conditional cash transfers, use of mini ambulances and wider use of Community Health Workers (CHWs)etc. to the whole country.  They can play a critical role in making further progress for women and children in Afghanistan.


Over the last decade, the financing of health systems in Afghanistan has increased with the support of international community. However, the country still faces huge challenges in providing financing for the basic health services in the country. As per the National Health Accounts (NHA) of 2014, 72% of the health expenditures in Afghanistan relies on out-of-pocket (OOP) spending; 23% relies on external aid and only 5% depends on the financing of the central government. Some of the potential drivers of such high OOP include high drug costs and payments for hospital care.