In 2003, Afghanistan’s Ministry of Public Health (MoPH) started the implementation of the Basic Package of Health Services (BPHS) and Essential Package of Hospital Services (EPHS). These frameworks specified health services at provincial levels, the type of facilities, quality of services, staffing and a uniform salary system. In 31 of the 34 provinces of the country, the implementation was contracted out to (international) non-governmental organisations ((I)NGOs) with external third party monitoring (TPM) all under the stewardship of the MoPH. The countrywide healthcare system was directly funded by USAID, the European Union (EU) and the World Bank (WB) until 2014. From then, the funding was centralised in the Afghan Reconstruction Trust Fund (ARTF) managed by the WB.

As a result of a country-wide system in which (I)NGOs were obliged to deliver on their contracts, access to healthcare hugely increased and health indicators drastically improved. Afghanistan has developed a functional healthcare system although funding has always been external with the exception of 3 provinces under MoPH management.

After 2010, emergency organisations started healthcare programmes outside the existing system. Maternity clinics were set up and due to the higher salaries offered here and exposure to expat staff, many healthcare staff including midwives who had trained under BPHS moved to these clinics. The involvement of these organisations ultimately undermined the governmental system where these services were already incorporated.

HealthNet TPO has been present in Afghanistan since 1994, providing healthcare services under different regimes, including the Taliban during 1996 - 2001. The organisation has implemented BPHS/EPHS since the start and has been instrumental to its development over the past 3 decades.

As of January 2019, HealthNet TPO has implemented these services in the provinces Kunar, Laghman and Nangarhar with around 2700 Afghan staff in 116 clinics, 6 provincial and districts hospitals as well as 3 separate Covid-19 hospitals. Next to that we manage a 120-bed Covid-19 hospital in Kabul. Our hospitals and clinics have been fully functional during and after the regime change in August 2021. All our staff continue to work, including female staff, with no objections from the new leadership.

The biggest problem of the BPHS/EPHS is the external funding facility that is with the ARTF/WB. The WB has frozen all funding towards Afghanistan. As a result, outstanding payments for the last six months have not been paid and instalments have not been issued. Normal services by (I)NGOs have had to continue without this funding.

At this moment, health facilities across the country have run out of medicines, oxygen, food for patients, fuel for generators and ambulances, and all other every-day commodities. Our dedicated staff are attending their workplace even though they have not received any salary payment for the last 3 months.

We are in frequent contact with the WB, EU, WHO and the Dutch government to advocate for solutions to fund the existing system.

A collapse of the healthcare system in place would lead to a severe humanitarian crisis for which huge amounts of emergency funds would be needed and non-familiar organisations would come in to the country to resolve a problem that could be prevented.
We believe that the WB has a moral obligation to solve the issues that arise from pausing funding to Afghanistan and not providing solutions. In our lobby we have also approached MSF and other organisations in order to see if they would be willing to fund or bridge a period of funding. But unfortunately they declined.

Due to continued lobbying, international organisations (WHO, UNOCHA, UNDP, GFATM, EU and others) have come up with some interim solutions. Funding for the month of October 2021 will be covered by The Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM), and under emergency funding of the UN CERF fund. The period of November 2021 till the end of January 2022 will be funded by the WHO/UNICEF with additional funds from the International Committee of the Red Cross (ICRC).

However, no long-term solution is in sight and no solution for outstanding payments has been reached.

(I)NGOS, including HealthNet TPO, have the staff in place, the systems in place, and are experienced in the provision of BPHS/EPHS - we just need the funds to operate. (I)NGOs still need to pay partial salaries and suppliers for which they are held accountable, whereas the WB seems to keep its head in the sand.

Additionally, funding for the specialised Covid-19 hospitals from November 2021 is not yet secured and this issue is still under discussion within the WHO.

So our main message is: the existing system is still in place and is functional. Donors need to get their act together and fund the system, otherwise the lives of ordinary Afghans will suffer the consequences and many preventable deaths will occur.