Donor dependency and financing challenges

Health funding in Afghanistan is still lacking: public sector financing is currently only 5% of total health expenditure, while household out-of-pocket expenditure represents 71.8%, 20.8% comes from international donors, and the remainder from other sources.

71.8%

40.4%

32.1%

Low income countries

Afghanistan

World

Out-of-pocket expenditures (% of total health expenditure) in Afghanistan, other low income countries, and the world's average. Sources: J Glob Health, WHO

AHDS’s Fareed believes donor dependency is one of the biggest issues currently facing the Afghan health system. There are lots of well-intentioned people in government but their approach is more project-based — short periods that are funded by different donors without thinking about the future, he said. Donors examine their funds and evaluate how much they have to spend for Afghanistan, and they select a number of priorities to fund for a certain period of time, he added.

“But what happens next?” he said.

This approach leaves NGOs such as AHDS in an uncertain situation. To address the issue, he would like the government to draft a more long-term strategic plan.

Dr. Ismail Hail, director of NGO Humanitarian Assistance & Development Association for Afghanistan, HADAAF, hopes to see increased domestic revenue allocated toward health, in addition to more domestic resource mobilization through more effective taxation and insurance schemes.

Dr. Ismail Hail (right), director of Afghan NGO HADAAF, hopes to see increased domestic revenue allocated toward health.

Cost-sharing programs could be considered, he said. Donors have also recently started to announce pay-for-performance based programs — where outcome funders pay investors back based on the performance of programs — something he considers problematic in a country where health care delivery is often interrupted by conflict.