Afghanistan National Health Accounts with Disease accounts 1393 ...

Islamic Republic of Afghanistan Ministry of Public Health

Afghanistan National Health Accounts with Disease Accounts, 2014

$1.99bn 1.43bn

0.46bn

0.10bn

(72%)

(23%)

(5%)

Out of Pocket

Rest of the World

Government

SHA.2011

Afghanistan National Health Accounts with Disease Accounts, 2014

Table of Contents Acronyms ............................................................................................................................................... v Acknowledgments ............................................................................................................................... vii General NHA Findings............................................................................................................ 1 Disease Accounts Findings ...................................................................................................... 1 Key Highlights ........................................................................................................................ 2 1.

Background ................................................................................................................................... 3 1.1. Health and Socioeconomic Status ................................................................................................ 3 1.2. Healthcare System ....................................................................................................................... 3 1.3. NHA Concept and Application .................................................................................................... 4 1.4. History of NHA in Afghanistan ................................................................................................... 4 1.5. Scope of the Third NHA Study .................................................................................................... 4 1.6. Policy Objective of the Third Round of NHA ............................................................................. 4 1.7. Organization of the Report........................................................................................................... 5

2.

Methodologies and Data Collection ............................................................................................. 6 2.1. Overview of Approach ................................................................................................................. 6 2.2. System of Health Accounts (SHA 2011) ..................................................................................... 6 2.3. Data Collection ............................................................................................................................ 7 2.4. Methods and Assumptions ........................................................................................................... 8 2.5. Limitations ................................................................................................................................... 9

3. General NHA Findings ................................................................................................................... 10 3.1. Summary of Findings in Comparison with Previous Rounds .................................................... 10 3.2. International Comparison of NHA ............................................................................................. 12 3.3. Expenditure by Financing Schemes ........................................................................................... 13 3.4. Expenditure by Financing Agents .............................................................................................. 16 3.5. Expenditure by Healthcare Providers ........................................................................................ 17 3.6. Expenditure by Healthcare Functions ........................................................................................ 18 ii | P a g e

3.7. Expenditure on Capital Formation ............................................................................................. 19 4.

Disease Accounts Findings ......................................................................................................... 20 4.1. Disease Expenditure by Financing Sources ............................................................................... 21 4.2. Disease Expenditure by Provider ............................................................................................... 23

5.

Conclusions and Recommendations .......................................................................................... 25 5.1. Conclusions ................................................................................................................................ 25 5.2. Recommendations ...................................................................................................................... 25

Institutionalization of NHA ................................................................................................................ 28 Annex A. National Health Accounts Tables, extracted from the NHA Production Tool ................. 29 Table A.1: Revenues of Healthcare Financing Schemes, by Financing Sources, FS x HF .............. 29 Table A.2: Financing Scheme, by Function, HC x HF ..................................................................... 31 Table A.3: Financing Scheme, by Healthcare Providers, HP x HF .................................................. 36 Table A.4: Healthcare Provider, by Function, HC x HP................................................................... 38 Table A.5: Financing Agent, by Financing Sources, HF x FA ......................................................... 46 Table A.6: Financing Sources, by Diseases, FS X DIS .................................................................... 47 Table A.7: Capital Expenditure, by Provider, HK x HP ................................................................... 49 Annex B: Classification of Health Expenditure / NHA Glossary ................................................... 50 Glossary ............................................................................................................................................... 51 References ............................................................................................................................................ 52

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List of Tables: Table 1: Summary of NHA Findings, 1st, 2nd, and 3rd Rounds .......................................................... 11 Table 2: Breakdown of Revenue of Healthcare Financing as Percentage of CHE ............................... 13 Table 3: Breakdown of Household Out-of-Pocket Expenditure ........................................................... 14 Table 4: Breakdown of Expenditure, by Public Financing Source ....................................................... 15 Table 5: Breakdown of Expenditure, Healthcare Providers.................................................................. 17 Table 6: Breakdown of Expenditure, by Functions .............................................................................. 18 Table 7: Breakdown of Capital Formation ........................................................................................... 19 Table 8: Breakdown of Disease, by Disease Category and Expenditure .............................................. 20

List of Figures Figure 1: Comparison of Total Health Expenditure (USD) Across Three Rounds of the NHA ........... 10 Figure 2: International Comparison of THE as a Percentage of GDP, 2014 ........................................ 12 Figure 3: Private Health Expenditure as a Percentage of THE, 2014 ................................................... 13 Figure 4: Breakdown of Financing Source ........................................................................................... 14 Figure 5: Composition of Household OOP Expenditure ...................................................................... 15 Figure 6: Breakdown of Public Financing Source ................................................................................ 16 Figure 7: Financing Agents Managing Healthcare Service Funds ........................................................ 17 Figure 8: Breakdown of Healthcare Providers ...................................................................................... 18 Figure 9: Breakdown of Healthcare Functions ..................................................................................... 19 Figure 10 : Breakdown of Disease Categories ...................................................................................... 21

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Acronyms AFN

Afghanis

AHS

Afghanistan Health Survey

AMIS

Afghanistan Financial Management Information System

ARI

Acute Respiratory Infection

ARCS

Afghan Red Crescent Society

ATM

HIV/AIDS, Tuberculosis, and Malaria

BPHS

Basic Package of Health Services

CH

Child Health

CHE

Current Health Expenditure

CIDA

Canadian International Development Agency

CSO

Central Statistics Organization

EMIS

Expenditure Management Information System

EPHS

Essential Package of Hospital Services

EU

European Union

FA

Financing Agent

GAVI

The Global Alliance for Vaccines and Immunization

GCMU

Grants and Contracts Management Unit

GDP

Gross Domestic Product

GIRoA

Government of the Islamic Republic of Afghanistan

HEFD

Health Economics and Financing Directorate

HH

Household

ICD

International Classification of Diseases

ICRC

International Committee of the Red Cross

IEC

Information, Education, and Communication

IFRC

International Federation of Red Cross and Red Crescent Societies

IOM

International Organization for Migration

IPD

Inpatient Department

ISAF

International Security Assistance Force

JICA

Japan International Cooperation Agency

MoD

Ministry of Defense

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MoE

Ministry of Education

MoF

Ministry of Finance

MoHE

Ministry of Higher Education

MoI

Ministry of the Interior

MoPH

Ministry of Public Health

NGO

Nongovernmental Organization

NHA

National Health Accounts

NPISH

Non-Profit Institutions Serving Households

NRVA

National Risk and Vulnerability Assessment

NDS

National Directorate of Security

OECD

Organization for Economic Cooperation and Development

OOP

Out of Pocket

OPD

Outpatient Department

RH

Reproductive Health

SBA

Skilled Birth Attendant

SHA

System of Health Accounts

TB

Tuberculosis

THE

Total Health Expenditure

TIKA

Turkish International Cooperation and Development Agency

UN

United Nations

UNFPA

United Nations Population Fund

UNICEF

United Nations Children's Fund

UNODC

United Nations Office on Drugs and Crime

USAID

United States Agency for International Development

USD

U.S. Dollar

WFP

World Food Programme

WHO

World Health Organization

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Executive Summary The Afghanistan National Health Accounts (NHA) study was undertaken to track the flow of funds in the health sector for 2014 and compare this round of findings with those of the NHA’s previous two rounds. NHA is an important tool for understanding the health financing of a country and provides a framework for measuring the total expenditure on health, including private households’ out-of-pocket (OOP) expenditures, government expenditure, and donors’ expenditures.

General NHA Findings

In 2014, Afghanistan’s total gross domestic product (GDP) was about 21 billion in U.S. dollars (USD), which shows an increase in economic growth compared with previous years. Total health expenditure (THE) in 2014 was about USD 1,992 million, an increase of approximately 32% compared to the previous round; government expenditure on health was around USD 97 million. THE as a percentage of GDP was about 9.5%, an increase of 1.5% compared to the previous round, but current health expenditure (CHE) as a percentage of GDP was about 9.3%. This round of NHA used the System of Health Accounts (SHA) 2011; thus, it separated expenditure on capital from the figure for CHE, which is approximately USD 1,958 million. Approximately 72% of THE was paid by households out of pocket; about 5% was financed by the government of Afghanistan and about 23% by international partners. The government of Afghanistan manages some of the funds provided by the donors, estimated at around 12.4% of CHE, whereas the donors themselves managed the balance of donor funding (15.5%). However, individual households managed and expended the amount spent OOP. A significant proportion of expenditure was incurred for the delivery of services by hospitals (39.8%); the second highest share was for outpatient care providers (26.4%), followed by retailers and other providers of medical goods (24.5%). Disease Accounts Findings Expenditure by disease was reported as per the classification of diseases in SHA 2011, which considers the most common diseases and issues in the country: infectious and parasitic infectious diseases (HIV/AIDS, tuberculosis [TB], and malaria [ATM]); reproductive health (RH) issues (maternal conditions, perinatal conditions, family planning, skilled birth attendance); and child health (CH) issues (acute respiratory infections, diarrheal diseases, malnutrition, anemia). CH consumed the highest percentage of expenditure among these disease categories, estimated at 25.2% of CHE, followed by RH (17.1%), parasitic infectious diseases (2.2%), and immunization (3.1%); the remaining 52.4% of CHE was spent for other diseases not classified in this round of the NHA. These findings indicate room for improvement in the disease accounts, particularly the inclusion of other diseases in future rounds of NHA reports.

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Key Highlights         

The NHA study estimated THE and CHE in this round of NHA at USD 1,992 million and USD 1,958 million, respectively; CHE excludes capital expenditure from THE. Total Health expenditure as a percentage of GDP was estimated at 9.5%. Public sector financing accounted for 12.4% of THE, including some donors’ funds transferred or channeled through the government. The government’s financing for healthcare from government revenue constituted 5% of CHE. Donors’ expenditures accounted for 22.9% of CHE for 2014. Household OOP expenditures on health totaled approximately USD 1,430 million, equivalent to 73.1% of CHE. Pharmaceuticals accounted for 24.5% of CHE. Hospitals accounted for the largest amount of expenditure at 39.7% of CHE; outpatient care centers accounted for 26.4%. The study estimated per capita expenditure on health at about USD 70.9 in 2014, whereas in 2008/2009 and 2011/2012 it was USD 42 and USD 56, respectively. This finding shows an increase of USD 15 per capita compared to the second round.

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1. Background 1.1. Health and Socioeconomic Status

Located in Central Asia, Afghanistan has a total population of approximately 28.1 million. It is a landlocked country with many harsh geographical features. Afghanistan consists of many ethnic, religious, and language groups. Almost two-thirds (73.1%) of its population live in rural areas, about one-third (23.1%) live in urban areas, and the remainder (5.3%) live as nomads. About 49% of the Afghan population is female; 51% is male. Rapid urbanization has become a major challenge in Afghanistan, as many people frequently migrate from rural areas to the cities. Regarding the age population pyramid, approximately 46.2% of the population is under 15 years of age; only 2.7% of its population is age 65 and over. Life expectancy at birth is approximately 63 years for men and 64 years for women (Central Statistical Organization, 2014). As for Afghanistan’s economics status, in 2014 the gross domestic product (GDP) was approximately U.S. dollars (USD) 21 billion, and GDP per capita was approximately USD 747―a decline of USD 25 compared to the previous year. The main reason for this decline was reported as due to a high inflation rate and the devaluation the Afghani (AFN) against the USD (Central Statistical Organization, 2014).

1.2. Healthcare System

Afghanistan’s health system and service delivery has improved significantly since 2002. The Ministry of Public Health (MoPH) has introduced health policies and strategies to strengthen the health system and improve service delivery. The Government of the Islamic Republic of Afghanistan (GIRoA), with financial and technical support from donors, introduced the Basic Package of Health Services (BPHS) in 2003. The main purpose of the BPHS is to deliver preventive and basic healthcare services that address the priority health needs of Afghanistan’s citizens, with a special focus on rural areas (MoPH, 2010). To complement the BPHS, the MoPH introduced the Essential Package of Hospital Services (EPHS) in 2005. The EPHS provides diagnostic and secondary treatment services through provincial and regional hospitals. Each provincial hospital works as a referral point for BPHS facilities. Primary and secondary healthcare services are provided through the BPHS and EPHS; tertiary healthcare is provided in Kabul’s national hospitals. The BPHS and EPHS are implemented by nongovernmental organizations (NGOs) in 31 provinces through a contracting-out mechanism. In the three remaining provinces, the MoPH delivers these services through a contracting-in mechanism called the Strengthening Mechanism (SM). The MoPH also manages the national hospitals. Improving the overall health status of Afghanistan’s people―especially women and children―is one of the priorities of the MoPH. The MoPH’s National Health Policy 2015– 2020 and National Health Strategy 2016–2020 (MoPH, 2015, 2016) specifically highlight increasing access to high-quality health services, improving health service delivery, and creating sustainable health financing for attaining universal health coverage. Understanding the performance in the management and use of funds for health enables the MoPH to allocate and spend its budgeted funds efficiently and advocate for more financing to achieve universal health coverage. Conducting National Health Accounts (NHA) regularly

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using international standards thus is highly recommended for tracking the resources used to cover the country’s health expenditures.

1.3. NHA Concept and Application The NHA framework measures current health expenditure (CHE) in a given country’s health system, including public, private, and donor spending. It tracks resources from their origin or source through the financing agents (FAs) who manage the funds to healthcare providers and health functions. In the System of Health Accounts (SHA) 2011 approach, diseases are also identified and disease accounts rather than sub-accounts used, based on the International Classification of Disease (ICD-10) (OECD, 2011). Such a disease-specific classification of health expenditures provides decision makers with the policy implications for different stakeholders. NHA tools focus on analysis of health financing and funding to incorporate macroeconomic trends among the institutions and organizations that constitute the health system. The results of the NHA approach also have had a significant impact on health financing flows and informing the process of health policy development in a particular country.

1.4. History of NHA in Afghanistan Afghanistan is one of the countries that produces NHA reports according to the standards of Organization for Economic Cooperation and Development (OECD) and World Health Organization (WHO) tools and frameworks. NHA findings have strongly influenced the policy-making process of the MoPH. The results of the first round of NHA, produced in 2011, stimulated discussion around the reported high out-of-pocket (OOP) expenditure in the country. Similarly, the second round of NHA in 2013 indicated no significant reduction in the share of OOP spending since the first round and made policy recommendations on the potential approaches to reducing such expenditure.

1.5. Scope of the Third NHA Study The scope of the study was wider in this round, although it aimed at the same purpose as previous rounds. In addition to providing general health expenditure information, it used the NHA and disease accounts methodology to produce expenditure information on selected health sector priorities: RH (antenatal/postnatal care, skilled birth attendance, and family planning); CH (acute respiratory infections, diarrhea, malnutrition, anemia, and immunization); and infectious and parasitic diseases (HIV/AIDS, tuberculosis [TB], and malaria [ATM]). In the 2011/2012 round, NHA sub-accounts were included only for reproductive health (RH). However, this report for the first time includes disease and services accounts for CH and ATM. To contribute to better programming, more detailed information on disease accounts is preferred; hence, the MoPH intends to include more disease accounts in future rounds.

1.6. Policy Objective of the Third Round of NHA Building on the same objectives as those of the NHA report for 2011/2012, more objectives were added following the newly published SHA 2011, as follows: 4|Page

     

To monitor CHE trends and provide a basis for the projection of future health financing needs To sustain capacity for the production and dissemination of NHAs in future years To motivate an evidence-based change in the public health budgeting process at both the central and provincial levels To identify disease expenditure by financing source, financing agent, and provider To enable the MoPH and other stakeholders to make decisions based on available information about the most common diseases in the country To compare expenditure by treatment of disease with expenditure by prevention services

1.7. Organization of the Report This report is organized into five sections: Section 1 provides background, objectives, and scope; Section 2 describes the methodology of the study and data collection; Section 3 contains general NHA findings; Section 4 provides disease accounts findings; and Section 5 lays out conclusions and recommendations. All imported tables with disaggregated data can be found in the annexes.

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2. Methodologies and Data Collection 2.1. Overview of Approach

The 2014 Afghanistan NHA was conducted in accordance with the SHA 2011 of the OECD and WHO’s Guide to Producing National Health Accounts, with Special Applications for Lowand Middle-Income Countries (WHO, 2003). The collected data were analyzed using the NHA production tool (V.4000). As based on the SHA 2011, the current round of NHA follows the six dimensions listed below (OECD, 2011):      

Financing schemes (HF): Components of a country’s health financing system that channel revenues received and use them to pay directly for or purchase goods and services inside health account boundaries Financing sources (FS): Revenues for health financing schemes received or collected through specific contribution mechanisms Financing agents (FA): Institutional units that manage health financing schemes Functions (HC): Types of goods and services provided and activities performed within health accounts boundaries Providers (HP): Entities that receive money in exchange for or in anticipation of producing activities inside health account boundaries Capital formation (HK): Types of assets that health providers have acquired during the accounting period and used repeatedly or continuously for more than one year in the production of health services

2.2. System of Health Accounts (SHA 2011)

Healthcare systems around the globe are developing rapidly. The factors driving these changes are innovations in healthcare interventions, pharmaceuticals, and medical technologies; increased demands for healthcare services; and the prevalence and incidence of diseases. As a result, the cost of healthcare has increasingly become a pressing subject of interest to policymakers, analysts, and the general public. This interest in turn fosters increased expectations for more detailed and sophisticated information that can be gained from the greater volume of health expenditure data now available. With this increased interest in healthcare financing, OECD, the European Union (EU), and WHO produced the SHA 2011. Although built on the SHA1.0, the SHA 2011 addresses the following issues in more detail: 





SHA 2011 has developed a healthcare financing interface to allow for a systematic assessment of how finances are mobilized, managed, and used, including financing arrangements (financing schemes), institutional units (financing agents), and revenueraising mechanisms (revenues for financing schemes). SHA 2011 has probed into the cost structures of healthcare provision and provided a separate treatment of capital formation to avoid some past ambiguity regarding the links between current health spending and capital expenditure in healthcare systems. SHA 2011 has improved the study and further analysis of the functional dimension of healthcare.

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

SHA 2011 has improved the breakdown of healthcare expenditure by beneficiary characteristics, such as disease, age, gender, region, and socioeconomic status.

In its effort to apply these improvements in the classification of the NHA, Afghanistan produced its third round of NHA using SHA 2011 while considering country context and the availability of detailed data.

2.3. Data Collection

For this round, the MoPH NHA team collected relevant expenditure data from development partners, NGOs, the Ministry of Finance (MoF), other relevant ministries, nonprofit institution service households, and household surveys. The team used SHA 2011 tools for the collection, analysis, and classification of the country’s 2014 health expenditure. To identify the household portion of the total health expenditure (THE), we included selected questions from the Afghanistan Household Survey (AHS) 2015. It provided us information on general OOP spending by households during 2014 and on specific expenditures on pharmaceuticals, diagnostics, transportation, and food, broken down by selected disease. Development Partner Surveys

The MoPH NHA team collected data from all development partners, including bilateral and multilateral organizations and United Nations (UN) agencies, through structured questionnaires. We used the MoPH International Relations Department (IRD) database to collect information on organizations, contacts, and addresses. We identified 37 international partners (donors) and requested that they provide data regarding their 2014 health expenditures. NGO Surveys

The MoPH is implementing two important packages of health services—the BPHS and EPHS, which cover primary and secondary healthcare services, respectively. The MoPH NHA team obtained from the Grants and Contracts Management Unit (GCMU) of the MoPH an extensive list of NGOs working in the health sector and implementing these packages and other vertical programs. These NGOs act as public providers, agencies, and financial sources for health expenditures. During an orientation workshop, we instructed representatives from implementing NGOs regarding the data required for the NHA and how to fill out the questionnaire. Following the orientation, NGOs completed survey questionnaires and returned them to the MoPH. Ministries Survey

The MoPH and four other ministries provide healthcare services to the people of Afghanistan— the Ministry of Defense (MoD), Ministry of Interior Affairs (MoI), Ministry of Higher Education (MoHE), Ministry of Education (MoE), as does the National Directorate of Security (NDS). The MoHE runs a large number of teaching hospitals nationwide. The MoE operates a number of health facilities at schools. MoE-supported health expenditure covers the cost of health education programs, pharmaceuticals, and salaries of health workers in the school-based health facilities. The NHA 2014 includes all costs incurred during the same year for all relevant ministries. Due to issues including but not limited to the confidentiality of expenditure data, the NDS did not cooperate with this survey. 7|Page

Household Survey

This round of NHA used household OOP data obtained from the AHS 2015. The MoPH NHA team developed a data collection tool for the NHA, in close collaboration with a third party, to collect information on households’ health expenditures. To collect information on these expenditures, the AHS 2015 included questions that covered facilities at which people had most recently sought treatment, the costs associated with their visits (e.g., diagnostics, pharmaceuticals, transportation, food, and consultation fees), the number of visits over the past 12 months (inpatient) or past two weeks (outpatient), and whether they stayed overnight.

2.4. Methods and Assumptions Disease-specific Data

The team conducted two stakeholders’ consultation workshops, during which it identified the most common RH and CH diseases based on SHA2011 classification. We used the BPHS health facilities costing study conducted by Health Economics and Financing Directorate (HEFD) to obtain outpatient department (OPD) costs of acute respiratory infection (ARI), diarrhea care, malnutrition, anemia, child immunization, family planning, antenatal care, postnatal care, and use skilled birth attendants. To obtain information related to ATM diseases and services, we obtained utilization data from the Health Management Information System (HMIS) for the specific year. We used this method specifically for public health facilities; for other vertical programs, we collected disease-specific expenditure data and allocated them to each service. During data collection, the NHA team faced some challenges, although compared to previous rounds, the quality of data improved a great deal. Improvements included a greater level of detail; enhanced consistency of the data; and a shortened timeframe for stakeholders’ compilation of data, as requested by the NHA team. During the data collection, the team observed some gaps in data quality but was able to collect data from other sources to crossverify and/or minimize the errors when producing the NHA report. The team used the following sources of information to collect primary and secondary data. Sources for the primary and secondary data We used secondary data collected from the HMIS, BPHS costing conducted by HEFD, and the MoF budget statement for 2014 (1393). We used the primary data collected from donors, NGOs, and other ministries via the data collection formats produced by the Health Accounts Production Tool (HAPT) (WHO, n.d.). We also obtained primary data on households’ health expenditures from the AHS 2015. The NHA technical team used the following methods for data collection and analysis: 1. BPHS allocation factor: We derived allocation factors for the selected diseases using the data obtained from the costing study that HEFD conducted in two provinces. 2. EPHS allocation factor: To account for health service expenditures from various financial sources, the NHA team used a hospital-level utilization rate and found allocation factors for each identified disease with the EPHS. We used the formula shown below for the calculation:

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𝑇𝑜𝑡𝑎𝑙 𝑤𝑒𝑖𝑔ℎ𝑡𝑒𝑑 𝑢𝑡𝑖𝑙𝑖𝑧𝑎𝑡𝑖𝑜𝑛 𝑜𝑓 𝑑𝑖𝑠𝑒𝑎𝑠𝑒𝑠 = % 𝑢𝑡𝑖𝑙𝑖𝑧𝑎𝑡𝑖𝑜𝑛 𝑓𝑜𝑟 𝑑𝑖𝑠𝑒𝑎𝑠𝑒𝑠 𝑎𝑙𝑙𝑜𝑐𝑎𝑡𝑖𝑜𝑛 𝑇𝑜𝑡𝑎𝑙 𝑤𝑒𝑖𝑔ℎ𝑡𝑒𝑑 𝑢𝑡𝑖𝑙𝑖𝑧𝑎𝑡𝑖𝑜𝑛 𝑓𝑜𝑟 𝑎𝑙𝑙 𝑠𝑒𝑟𝑣𝑖𝑐𝑒𝑠 3. MoPH ordinary budget: The team allocated a proportion of the ordinary MoPH budget toward selected diseases at both the central and provincial levels. To clarify the details of expenditures, the budget assesses changes in financing patterns for family planning and reproductive health (RH). We included the following issues for the measurements RH, CH and ATM. As the ordinary budget covers only staff salaries, we gathered data regarding the total number of staff working in RH, CH, and ATM services at the MoPH central and provincial levels. 4. Survey of National Hospitals: RH cost allocation factors for gynecology, family planning, and obstetric services were determined when HEFD conducted the cost analysis for the Kabul National Hospitals (GIRoA, 2014). As per that study, the allocation factors of inpatients and outpatients were 81% and 19%, respectively.

2.5. Limitations

Despite significant improvements in the quality of data as a result of enhancements in methodology and recent improvements in the capacity of stakeholders involved with their production, a number of limitations still exist regarding production of the NHA 2014 that must be addressed during the next NHA rounds. For this reason, we recommend that readers exercise caution when using these estimates.

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3. General NHA Findings 3.1. Summary of Findings in Comparison with Previous Rounds Total Health Expenditure in Afghanistan Three rounds of the Afghanistan NHA have demonstrated that THE across all three rounds has increased incrementally. In the first round of the NHA, THE was estimated at approximately USD 1 billion; it increased by about 50% to reach approximately USD 1.5 billion during the second round of estimations in 2011/2012. However, the NHA 2014 indicated that THE has increased by almost 33% in nominal terms and accounts for USD 2 billion; the share of household expenditure on health has dropped slightly, from 75% to 72%. Figure 1 shows the trend in THE in nominal terms across the three rounds of the NHA.

Figure 1: Comparison of Total Health Expenditure (USD) Across Three Rounds of the NHA 2,500,000,000

2,000,000,000

1,500,000,000

1,000,000,000

500,000,000

2008-2009

2011-2012

2014

Composition of THE

Although the estimated THE of USD 1,992,000,402 in 2014 shows an increase of about 33% over the second round, the government expenditure on health as a share of THE increased by only 0.1% (approximately USD 97,128,992 USD). THE as a percentage of GDP is about 9.5%—an increase of 1.5% compared to the previous round―but the CHE as a percentage of GPD is about 9.3%. The difference in the CHE and THE in their percentage share of the GDP is due to the exclusion of capital formation from the CHE. With the capital expenditure reported separately, the CHE is around USD 1,958,143,950. To allow for comparability, one can sum the capital expenditure with CHE. Considering the overall increment in THE, per capita health expenditure also increased to USD 70.9. This round of NHA showed a minor decrease in the share of household OOP expenditure, at 72%, whereas in nominal terms it has increased significantly. Despite increased government investment in primary healthcare services, high household OOP expenditure is a matter of serious concern. 10 | P a g e

Table 1 provides a comparative summary of the three rounds of the Afghanistan NHA. Table 1: Summary of NHA Findings, 1st, 2nd, and 3rd Rounds General NHA Indicators 2008/2009 2011/2012 2014 Total population 25,011,400 27,000,000 28,100,000 Total GDP (USD) 10,843,340,000 18,952,000,000 21,010,912,250 1:57 Average exchange rate (USD: AFN) 1:50 1:47 Total government health expenditure 97,128,992 63,892,239 84,148,093 (USD) Current Health Expenditure (CHE) 1,958,143,950 THE 1,043,820,810 1,500,975,945 1,992,000,402 70.9 THE per capita (USD) 41.73 55.59 THE as % of GDP 10.0% 8.0% 9.5% Government health expenditure as % 4.3% 4.0% 4.2% of total government expenditure Financing Source as a % of THE 5.0% Central government 6.0% 5.6% Private 76.0% 73.6% 72.0% Other countries in the world 18.0% 20.8% 23% Household (HH) Spending Total HH (OOP) spending as % of 75.0% THE Total HH (OOP) spending per capita 31 (USD) Financing Agent Distribution as a % of THE Central government 11.0% Household 75.0% NGOs 5.0% Other countries in the world 8.0% Provider Distribution as a % of THE Hospitals 29.0% Outpatient care centers 32.0% Retailers and other providers of 28.0% medical goods Other 11.0% Function Distribution as a % of THE Curative care 59.0% Pharmaceuticals 28.0% Prevention and public health programs 5.0% Health administration 5.0% Capital formation 2.0% Ancillary services Other 1.0%

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73.3% 41

71.8% 51

11.8% 73.3% 0.3% 14.6%

12.4% 71.8% 0.3% 15.5%

24.0% 25.0%

39.8% 26.4% 24.5%

26.0% 25.0%

9.2%

37.0% 26.0% 5.0% 6.0% 1.0% 24.0% 1.0%

32.7% 41.7% 6.8% 4.3% 1.7% 12.6% 0.2%

3.2. International Comparison of NHA

Contrary to the prevailing perception of the Afghanistan Health System being highly donor dependent, the highest burden of healthcare cost is being borne by the public, as evidenced in the results of the three NHA rounds. Figure 2 shows that Afghanistan finances the highest share of THE of all countries in the region out of its citizens’ pockets. THE is approximately 9% of the country’s GDP—other countries range from 3% to 7%.

Figure 2: International Comparison of THE as a Percentage of GDP, 2014 10 9 8 7

6 5

9.3

4

7

3 2

3

1

5

4

6 4

3

0 Afghanistan

Pakistan

Kazakhstan

Tajikistan

Bangladesh

India

Nepal

Sri Lanka

Source: Global Health Expenditure database.

Comparison of OOP with other countries The graph in Figure 3 shows a comparative picture of private health expenditure as a percentage of the THE in low- and middle-income countries. As indicated, Afghanistan has the second highest OOP expenditure after Cambodia. In 2014, households’ OOP expenditures were lowest in Iraq, Kazakhstan, and Sri Lanka.

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Figure 3: Private Health Expenditure as a Percentage of THE, 2014 90 80 70 60 50 40 30 20

72

40

78

71

65

59

46

47

60 44

10 0

Source: Global Health Expenditure database.

3.3. Expenditure by Financing Schemes

Financing schemes for health in Afghanistan mainly derive from three major players: (1) the government, (2) donors, and (3) private households’ OOP expenditure. Government domestic revenue made up 5% of CHE, and government spending funded by donors accounted for 7.6%; this spending is managed by the government through a nondiscretionary budget. Households’ OOP expenditures accounted for the highest share—73.1% of CHE. International donors’ spending on health accounted for 14.2% of health expenditures. Table 2: Breakdown of Revenue of Healthcare Financing as Percentage of CHE Breakdown of Expenditure, by Financing Schemes Revenues of Healthcare Financing Schemes Transfers from government domestic revenue (allocated to health purposes) Transfers distributed by government from foreign origin Private (household OOP) Other revenues from nonprofit institutions serving households (NPISH) not elsewhere classified Direct foreign transfers Total

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Amount

97,128,992

Percentage

5.0%

147,865,516 1,430,540,103 3,725,504

7.6% 73.1% 0.2%

278,883,835 1,958,143,950

14.2% 100%

14%

5% 8%

Transfers from government domestic revenue (allocated to health purposes) Transfers distributed by government from foreign origin

0%

Private (Household Out of Pocket)

Other revenues from NPISH n.e.c.

Direct foreign transfers 73%

Figure 4: Breakdown of Financing Source

Household OOP Health Expenditure

Using data obtained from the AHS 2015, this round of NHA showed that approximately threequarters of THE was borne by households. The analysis shows that the 2014 OOP expenditures of USD 1,430,540,103 were approximately equal to the 2011–2012 THE in nominal terms. The providers and services for which household expenditure was incurred were the following: hospitals, 13.5%; ambulatory healthcare centers, 9.8%; retail sales (medicines), 57.4%; and diagnostics, 18.7%. The MoPH leadership and other interested stakeholders should collaborate to design and implement risk protection mechanisms aimed at reducing OOP payments at the point of service and speed up the move toward universal health coverage. Table 3 and Figure 5 show the details of household OOP expenditures, which consist of expenditures on OPD, inpatient department (IPD), retailers and other providers of medical goods and medicines, and diagnostics. The largest health expenditures by households were for retail sales and medical goods and medicines consumed. Table 3: Breakdown of Household Out-of-Pocket Expenditure Household OOP expenditures Outpatient Inpatient Retailers and other providers of medical goods and medicines Vision products Hearing products Medicines Diagnostics Total HH expenditure

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Amount 192,688,689 140,834,957 829,727,640 6,331,786 1,948,242 821,447,612 267,288,818 1,430,540,103

Percentage 13.5% 9.8% 58.0% 0.4% 0.1% 57.4% 18.7% 100.0%

OPD

13%

19%

10%

IPD

Retailers & other providers of medical goods & Medicine 58%

Diagnosis

Figure 5: Composition of Household OOP Expenditure Public Health Expenditure Public expenditure by financing scheme is depicted in Table 4. It includes government expenditures on health and funds from international partners distributed to the health sector through government on-budget channels. Public expenditure on health was USD 523,878,343, which also included donors’ expenditures on health through on-budget and off-budget channels. Out of that total amount, approximately USD 426,749,351 was paid by international donors, consisting of USD 147,865,516 and USD 277,145,437 through on- and off-budget channels, respectively. The remaining USD 97,128,992 was spent by GIRoA through different ministries; the MoPH had the highest percentage of expenditure among them. Table 4: Breakdown of Expenditure, by Public Financing Source Public Expenditure Revenues of Healthcare Financing Schemes as a Percentage of CHE (USD) Financing schemes Amount Transfers from government domestic revenue 97,128,992 (allocated to health purposes) MoPH 84,546,008 MoD 2,519,643 MoI 2,180,089 MoHE 7,674,712 MoE 208,539 Transfers distributed by government from foreign origin 147,865,516 Direct donors’ expenditures on health 277,145,437 Other domestic revenue 3,725,504 Total 527,603,846

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Percentage 18.47% 87.0% 2.59% 2.24% 7.90% 0.21% 28.12% 52.70%

0.71% 100.00%

1% Ministry of Public Health 16%

1% 0% 1%

0%

Ministry of Defense Ministry of Interior Affairs Ministry of Higher Education

53%

Ministry of Education 28%

Transfers distributed by government from foreign origin Donors Expenditure on health as public Other Domestic Revenue

Figure 6: Breakdown of Public Financing Source Donor Health Expenditure

In 2014, international partners (donors) contributed USD 426,749,351 for health in Afghanistan through both on- and off-budget channels to support implementation of the BPHS and EPHS via contracting out and contracting in (MoPH-SM) service delivery mechanisms. This contribution comprised 21.8% of CHE.

3.4. Expenditure by Financing Agents

Various agents manage health expenditures in Afghanistan. Consistent with the previous round of NHA, the 2014 round showed that households managed and paid for almost three-quarters of health expenditure. In the absence of prepayment mechanisms, OOP expenditure occurs for various reasons, and is not an efficient method of financing healthcare services. However, even though GIRoA financed only 5% of CHE, it managed almost 12.5% of it in 2014. Despite the commitment of donors and international partners to spend their money targeted at the health system through the government financing system as on-budget spending, donors still directly manage about 14% of their funds. To ensure that government institutions’ performances improve further, this aid should be channeled through the government’s systems and spent based on MoPH priorities.

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13%

14%

Central Government

0%

Households Non-Provite Institution iserving households Rest of the World (RoW)

73%

Figure 7: Financing Agents Managing Healthcare Service Funds

3.5. Expenditure by Healthcare Providers

As indicated in the following table, hospitals provided services equivalent to almost 40% of CHE and thus held the highest-rank in the list of providers. Outpatient care centers ranked second as providers of healthcare services (equivalent to 25.5% of CHE), and retailers and other providers of medical goods ranked third, (equivalent of 29.4% of CHE). Finally, provision and administration of public health programs, and general health administration made up 4.3% and 4.4% of CHE, respectively, whereas less than 1% (0.7%) was provided by “All others”―not classified. Table 5: Breakdown of Expenditure, Healthcare Providers Breakdown of Health Providers Health providers Hospitals Outpatient care centers Residential and long-term care Retailers and other providers of medical goods/Medicine Provision and administration of public health programs General health administration All others Total

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Amount

783,216,631 499,635,911 3,320,000 487,937,871 84,173,402 85,811,871 14,048,264 1,958,143,950

Percentage

40.0% 25.5% 0.2% 24.9% 4.3% 4.4% 0.7% 100%

0.7%

Hospitals

4.4% 4.3%

Outpatient care centers

40.0%

24.9%

Residential and long term care Retialers & other providers of medical goods/ medicine Provision and administration of public health programs

0.2%

General health administration 25.5%

All others

Figure 8: Breakdown of Healthcare Providers

3.6. Expenditure by Healthcare Functions This round of NHA classified the following functions. Expenditure on curative care—including both inpatient and outpatient curative care—accounted for 33.27% of CHE; out of this percentage, 50% was spent on OPD and 50% on IPD. The highest percentage of current expenditure was for medical goods dispensed to outpatients, accounting for 42.41%, followed by 12.83% on ancillary services, 6.89% on prevention and public health programs, and 4.38% on health system administration. Table 6: Breakdown of Expenditure, by Functions Expenditure by Function Healthcare Functions

Amount

Curative Inpatient curative care

651,466,893 33.27% 325,399,660 49.95% 326,067,232 50.05% 4,195,472 0.21% 251,208,810 12.83% 830,374,513 42.41% 134,897,107 6.89% 85,790,404 4.38% 210,751 0.01% 1,958,143,950 100%

Outpatient curative care Rehabilitation care Ancillary services Medical goods dispensed to outpatients Prevention and public health services Health administration of public health programs All others Total

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Percentage

0% 7%

Curative

4%

Rehablitation care 33%

Ancillary services Medical goods dispensed to outpatients

43%

0% 13%

Prevention and public health services Health administration of public health programs All others

Figure 9: Breakdown of Healthcare Functions

3.7. Expenditure on Capital Formation Capital formation is defined as the type of investment that healthcare providers have made during the accounting period that last for more than one year and cost more than $100 in producing health. Table# 7 shows that in 2014, the expenditure on capital formation was financed by donors and the government. Table 7: Breakdown of Capital Formation Financing agents

Nonproduced non-financial assets

All Unspecified gross fixed capital formation (n.e.c.) 5,846.5

7,830,632.1

7,824,785.6

5,846.5

7,830,632.1

Other countries in the world

25,934,249.8 43,616.0

47,954.5

26,025,820.3

All

33,759,035.4 43,616.0

53,801.0

33,856,452.4

General government MoPH

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Gross capital formation 7,824,785.6

4. Disease Accounts Findings The 2014 NHA was the first round in which the most common diseases were identified based on the SHA classifications. Based on our analysis, approximately 2.2% of CHE was spent on HIV/AIDS, TB, and malaria. Expenditures on other diseases and services consisted of the following: 17.1% on RH (maternal conditions, perinatal conditions, contraceptive management/family planning, and use of skilled birth attendants); 25.2% on childhood diseases (acute respiratory infection, diarrheal diseases, malnutrition, and anemia); and more than 50% on other diseases and services. The magnitude of expenditure on these others and the need for evidence-based planning will require inclusion of more disease accounts in the future. Table 8: Breakdown of Disease, by Disease Category and Expenditure Expenditure by Disease Category Disease categories Code DIS.1 Infectious and parasitic diseases DIS.1.1.1.1 HIV/AIDS DIS.1.2 TB DIS.1.3 Malaria DIS.2 Reproductive health DIS.2.1 Maternal conditions DIS.2.2 Perinatal conditions DIS.2.3 Contraceptive management (family planning) DIS.2.4 Skilled birth attendant (SBA) DIS.7 Child health diseases DIS.7.1 Acute respiratory infection (ARI) DIS.7.2 Diarrheal diseases DIS.7.3 Malnutrition (nutritional deficiencies) DIS.7.4 Anemia DIS.7.5 Child immunization DIS.nec Other diseases not classified above Total

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Amount Percentage 42,361,392 2.2% 4,025,392 0.2% 21,368,799 1.1% 16,967,201 0.9% 334,458,863 17.1% 58,832,690 3.0% 90,085,675 4.6% 88,431,439 4.5% 97,109,058 5.0% 494,109,515 25.2% 283,794,526 14.5% 96,941,469 5.0% 97,035,658 5.0% 16,337,862 0.8% 60,756,786 3.1% 1,026,457,394 52.4% 100% 1,958,143,950

2.2%

17.1%

Infectious and parasitic diseases Reproductive health

Child health diseases 52.4% 25.2%

3.1%

Child immunization Other disease not classified above

Figure 10 : Breakdown of Disease Categories

4.1. Disease Expenditure by Financing Sources Table 9 is important for international partners supporting vertical programs―it indicates which partners spent how much for which disease. In this round of NHA, we produced expenditureby-disease categories and accompanying financing sources, thus identifying the key players and how much each of them spent on each disease.

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Table 9: Disease Expenditure, by Financing Sources

Disease categories Infectious and parasitic diseases HIV/AIDS TB Malaria Reproductive health Maternal conditions Perinatal conditions Family planning SBA Child health diseases ARI Diarrheal disease Nutritional program Anemia Immunization Other diseases not classified above Total

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Transfers from government domestic revenue (allocated to health purposes)

Transfers distributed by government from foreign origin

Other domestic revenues (other revenues from NPISH) n.e.c.

Direct foreign transfers

313,148 86,199 4,349,710 697,618

1,480,000 199,353 1,701,682 2,208,602 5,292,442

78,349 806 4,647 358,809 57,721

1,215,935 1,132,664 1,303,493 6,171,551 2,690,216 2,296,284 819,049 366,002

8,843,110 8,581,442 9,491,609 0,531,114 6,813,457 8,036,760 4,076,961 1,603,935

2,127,764 4,080,619 97,128,992

399,347

3,381,036

83,802

30,160,280

Private Expenditure on Health (households’ OOP expenditures)

Total expenditure on all diseases

8,336,927

42,361,392

2,467,044 18,158,951 9,534,286 22,537,425 8,545,440

2,696,541 5,640,387 275,004,316 44,239,469

4,025,392 21,368,799 16,967,201 334,458,863 58,832,690

98,905 96,024 106,160 409,459 281,491 70,606 39,224 18,138

4,123,682 5,025,149 4,843,153 63,015,103 7,083,140 3,320,179 52,163,493 448,290

75,804,044 73,596,160 81,364,643 383,982,288 246,926,222 83,217,639 39,936,930 13,901,497

90,085,675 88,431,439 97,109,058 494,109,515 283,794,526 96,941,469 97,035,658 16,337,862

7,475,741 4,269,024

72,551 800,883

51,080,730 12,090,297

763,216,572

60,756,786 1,026,457,394

47,865,516

3,725,504

278,883,835

1,430,540,103

1,958,143,950

4.2. Disease Expenditure by Providers Table # 10 shows the major providers of healthcare for selected diseases during the accounting period: hospitals, ambulatory healthcare, providers of ancillary services, retailers and other providers of medical goods, and providers of preventive care.

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Infectious and parasitic diseases HIV/AIDS and other sexually transmitted diseases (STDs) HIV/AIDS and opportunistic infections (OIs) HIV/AIDS

17,856,620

5,827,502

344,409

0

2,045,654

Unspecified healthcare providers (n.e.c.)

Other countries of the world

Rest of economy

Providers of healthcare system administration and financing

Providers of preventive care

Retailers and other providers of medical goods

Providers of ancillary services

Providers of ambulatory healthcare

Hospitals

Healthcare providers Classification of diseases / conditions

Residential longterm care facilities

Table 10: Disease Expenditure, by Providers

752,863

0

Total

13,340,650

2,538,103

0

42,361,392

2,142,487

1,171,384

367,113

4,025,392

344,409

2,142,487

1,171,384

367,113

4,025,392

344,409

2,142,487

1,171,384

367,113

4,025,392

TB

14,705,458

803,605

146,118

3,976,377

1,737,241

21,368,799

Tuberculosis treatment (general) Malaria

14,705,458

803,605

146,118

3,976,377

1,737,241

21,368,799

8,192,889

16,967,201

2,806,753

2,881,411

1,899,536

433,749

752,863

Reproductive health

9,458,374

157,255,501

163,798,431

2,981,848

4,480

960,228

334,458,863

Maternal conditions

1,624,855

29,137,758

26,349,971

1,278,667

2,050

439,390

58,832,690

Perinatal conditions

2,611,173

41,483,859

45,150,504

639,876

930

199,333

90,085,675

Contraceptive management (family planning) SBA

2,424,661

42,096,380

43,835,441

74,958

Child health diseases

2,797,685 100,302,413

44,537,505 0

195,733,332

48,462,515 0

179,433,072

11,367,174

88,431,439

988,348

1,500

321,505

3,406,295

524,024

3,343,205

97,109,058 0

494,109,515

ARI

43,646,847

112,500,846

125,174,537

1,626,952

294,500

550,845

283,794,526

Diarrheal disease

40,725,608

26,366,174

29,126,215

437,061

68,575

217,836

96,941,469

Malnutrition (nutritional deficiencies)

15,472,018

49,424,622

16,852,292

1,240,072

141,394

2,538,087

97,035,658

Anemia

19,556

36,437

0

7,660,664

0

0

52,463,655

408,842

77,877

145,749

0

60,756,786

Others

655,599,224

3,320,000

133,158,911

1,520,833

142,660,714

7,001,923

76,476,783

1,486,636

5,076,362

156,008

1,026,457,394

Total

783,216,631

3,320,000

499,635,911

1,520,833

487,937,871

84,173,402

85,811,871

2,845,880

9,525,544

156,008

1,958,143,950

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7,441,690

8,280,028

16,337,862

102,211

0

Child immunization

457,940

11,367,174

5. Conclusions and Recommendations 5.1. Conclusions Deviating from the previous two rounds, this round of NHA followed the SHA 2011 framework to provide comprehensive information on the volume and composition of health expenditure in Afghanistan. In addition to tracking health expenditures by financing sources, schemes, agents, providers, and functions, for the first time in Afghanistan this round also produced disease accounts for four disease categories: infectious and parasitic diseases, RH, CH diseases, and immunization. Over a two-year period (2011/2012 to 2014), THE increased by 32.7%, accounting for 9.5% of the GDP―equivalent to USD 70.9 per capita in 2014. Although health expenditure has increased substantially from the previous round, the composition of health expenditure follows almost the same pattern to that of the previous NHA. Consistent with previous rounds of the NHA, the 2014 round revealed that Afghanistan remains highly dependent on OOP expenditure and donor support to finance its health system. The share of OOP remained high, at 72%, which is a major policy concern for the MoPH because such expenditures can lead to financial catastrophe and impoverishment. Also, the share of government financing in THE fell from 5.6% in 2011/12 to 5.0% in 2014, although the burden of disease increased. By disease category, CH consumes the largest share (25.2%) of the current health expenditure, followed by RH (17.1%).

5.2. Recommendations We make the following specific recommendations based on the findings. 



Design and implement financial risk protection mechanisms for households: GIRoA has been providing healthcare services free of charge at the point of delivery in all public health facilities. Nevertheless, the share of OOP expenditure has hardly been reduced over the years, as seen in the different rounds of the NHA. Current per capita direct expenditure by households in the form of OOP expenditure is USD 51, and there are no mechanisms in place to prevent financial risk due to ill health. As OOP spending is regressive in nature, it not only poses severe barriers in accessing healthcare for individual households but also exacerbates inequity, particularly affecting rural, poor, and vulnerable populations. A large share of OOP spending can lead to catastrophic expenditure, which pushes households further into debt and forces them to sell assets or compromise on their health by not seeking care. Thus, the government should consider designing and implementing prepaid mechanisms, such as health insurance, to improve financial protection as an interim move toward universal health coverage. Such mechanisms, in addition to generating additional domestic resources for the health sector, could also promote efficiency through strategic purchasing. Increase government investment in health and broaden the package of health services: Afghanistan is facing a double burden of communicable and non-

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communicable diseases during a time that the government financing in total health expenditure has decreased. The share of total government expenditure on health is also substantially lower than international benchmarks. Thus, delivery of services in public health facilities is constrained by limited resources, which may drive patients from public to private facilities. To avoid such a situation and ease people’s access to essential health services, the government should consider allocating more resources to the health sector to strengthen health services in public facilities. With increased government funding, the MoPH may also need to consider revisiting the list of services in the BPHS and EPHS to expand their scope to better address the emerging healthcare needs of the population. The “youth bulge” and an expected reduction in donor funding inevitably must force an exploration of new streams of revenues, such as earmarking of “sin taxes” (e.g., tobacco tax) for the health sector. Earmarking such taxes can reduce health risks among the population by curtailing the use of harmful products while generating more resources for the sector. A continuous evidence-based dialogue with the MoF and other stakeholders should be conducted to advocate for an increased budget allocation or earmarked taxes for health. 

Promote rational use of medicines and cost containment measures: Pharmaceuticals and other medical non-durables make up the bulk of household health expenses, with a significant proportion dispensed through pharmacies and retail shops. In addition to genuine need, there are a number of reasons for this high level of spending on medicines, which are also highlighted in the newly endorsed National Health Strategy 2016–2020. First, not only do doctors frequently overprescribe medications, but patients often demand medications that are not clinically indicated. Second, patients commonly overuse medicines because they often ask private pharmacies to prescribe medicines, even though a majority of pharmacies do not have qualified pharmacists. Third, anecdotal evidence suggests that a significant number of pharmaceutical products are also purchased through illegitimate channels. Thus, the MoPH may need to further assess the country’s drug consumption patterns and promote rational use through an awareness campaign and effective regulation. Further, as the prices of medical goods and services are increasing at a higher pace than general inflation, the government should also prioritize the containment of these prices.



Improve understanding of investments in preventive care: Expenditure on preventive care increased slightly in this round of NHA compared with previous rounds; expenditure on immunization also increased. Under the BPHS and EPHS, physicians and other medical personnel conduct certain preventive activities, including counseling, screening, and vaccinations; and blood pressure, cholesterol, and diabetes tests. However, the time and resources spent on these activities are considered curative under the NHA because they are provided as both inpatient and outpatient services. Thus, government expenditure on preventive health is likely underestimated.

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

Leverage and regulate the private sector through implementation of the MoPH Private Sector Strategy: With healthcare demands outpacing the supply of services and available resources, the BPHS and EPHS are not adequate to fulfill all of the healthcare needs of the population. Given the low level of government resources allocated to health, sustainability of the BPHS and EPHS depend heavily on donor funding. In this situation, the MoPH should begin leveraging the private sector, given its increasing role in health service delivery. Achieving public health goals will also require more effective use of private resources; thus, the MoPH Private Sector Strategy should be implemented to increase that sector’s overall contribution to health. Engaging and building partnerships with the private sector will enable the public sector to ensure better quality and best practices across providers nationwide. Thus, the government should provide a friendly environment that will foster competition within the private sector, or between the public and private sector, and ensure the quality of services delivered by both. Furthermore, better engagement of the private health sector can help to alleviate the burden of financing the public health system.



Continue efforts for institutionalizing the NHA: The MoPH has made significant efforts to strengthen the NHA production process, as demonstrated by successive improvements in the methodology and scope of the analysis in the three NHA rounds. The HEFD has also become increasingly capable of producing the NHA with a reduced level of external support―a key development in the institutionalization process. The HEFD should continue to advocate for producing the NHA on a regular basis, rely more on routine information systems, such as the Expenditure Management Information System (EMIS) and Afghanistan Financial Management Information System (AFMIS), and further build the capacity of the NHA team. Moreover, it is crucial to have NHArelated staff financed through the government’s annual ordinary budget to ensure greater sustainability. The NHA technical team should continue to improve the methods and systems for collecting and analyzing data, expand to cover more diseases, and implement the ICD-10 in future rounds.

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6. Institutionalization of NHA The NHA is recognized internationally as a strong tool for providing more detailed information on health systems expenditures at the national level. NHA continuously collects and analyzes data that can have a strong impact on policymakers, encouraging them to change or amend strategies and planning of health systems to benefit all citizens. The NHA concentrates on tracking the resources spent for health, which can contribute to improved allocation of funds and reprioritize the delivery of services, programs, and projects. The role of the NHA in the health system is progressing as its scope has expanded over the course of the different rounds. However, challenges in institutionalizing the NHA continue to exist. The establishment of an NHA office within the HEFD is encouraging. The NHA team consists of several technical and experienced staff who have worked tirelessly and produced the three rounds of NHA within the framework of SHA.1 and SHA 2011, according to their corresponding guidelines. The quality of data collected and analyzed has met the international standard. The confidential nature of financial data to be collected was one of the team’s main challenges, and some of partners still have not shared their expenditure data. Despite such challenges, the NHA team has obtained high-quality data from international donors, ministries, and households to ensure the accuracy and validity of NHA results. Against all odds and in the face of the challenges existing within Afghanistan’s health sector, the MoPH has managed to develop and implement EMIS as an effective step toward simplifying the process of collecting data on health expenditures. The MoPH’s successful implementation of EMIS may allow its partners to record their health expenditures and report them more accurately and easily. The HEFD team of the MoPH designed EMIS in a very comprehensive manner and plans to migrate it to a web-based system. Effective implementation of the EMIS can contribute significantly to institutionalizing the NHA, mainly by routinely providing disaggregated expenditure data. In addition, the MoPH and the Central Statistics Organization (CSO) are working progressively to improve the quality of household expenditure data by conducting regular multidimensional household surveys at the national and community levels. These organizations signed a memorandum of understanding (MoU) in September 2011. Based on this MoU, both partners are obliged to work together to conduct surveys of households and communities. All parties are accountable for data sharing and data analyses based on mutual trust. Such regular household surveys will also help the institutionalization of the NHA in Afghanistan. The MoPH has incorporated questions related to health expenditure in household surveys, such as the National Risk and Vulnerability Assessment (NRVA), which is conducted nationally. The NRVA systematically collects relevant data on OOP health expenditures and has obtained high-quality data regarding OOP expenditures from its various health partners. For this round of the NHA, the team obtained data for household expenditure on health from the AHS 2015. Finally, the NHA team also is accountable for developing a method of analysis to determine household expenditure according to the standards and recommendations of international stakeholders to achieve a better comparison with previous years’ data.

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Annex A. National Health Accounts Tables, extracted from the NHA Production Tool Table A.1: Revenues of Healthcare Financing Schemes, by Financing Sources, FS x HF

FS.6.3 FS.7.1.4 FS.8.1 All FS Data sources used: Donors

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7,674,712

208,539

121,619,566 19,077,798

7,168,152

HF.3.1

All HF

Out-of-pocket, excluding cost sharing

2,180,089

HF.2.2.2 Resident foreign agencies’ schemes

Ministry of Education

2,519,643

84,546,008

NPISH financing schemes (excluding HF.2.2.2)

Ministry of Higher Education

HF.1.1.1.3 HF.1.1.1.4 HF.1.1.1.5 HF.2.2.1 Ministry of Interior Affairs

FS.2

Central government revenue Transfers distributed by government from foreign origin Other revenues from NPISH n.e.c. Direct foreign financial transfer Households’ OOP

HF.1.1.1.2 Ministry of Defense

Revenues of healthcare financing schemes FS.1.1.1

Ministry of Public Health

Reported currency: US Dollar Financing HF.1.1.1.1 schemes

97,128,992 147,865,516

3,725,504

3,725,504 278,883,835

278,883,835 1,430,540,103 1,430,540,103

206,165,574 21,597,442

9,348,241

7,674,712

208,539 3,725,504 278,883,835 1,430,540,103 1,958,143,950

USAID, European Union (EU), United Nations Population Fund (UNFPA), WHO, United Nations Children’s Fund (UNICEF), World Food Program (WFP), Japan International Cooperation Agency (JICA), United Nations Office on Drugs and Crime (UNODC), MSF, International Security Assistance Force (ISAF), Emergency, Afghan Red Crescent Society (ARCS), Canadian International Development Agency (CIDA),

NGOs Government sources Households

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Turkish International Cooperation and Development Agency (TIKA), International Federation of Red Cross and Red Crescent Societies (IFRC), Global Alliance for Vaccines and Immunization (GAVI) HSS, CIDA1, EU, EU2, AKDN , HANDICAP, SOZO Int, International Organization for Migration (IOM), Italian cooperation, Medair, IAM, International Committee of the Red Cross (ICRC) SDO, SCA, BDN, PU-AMI, HADAAF, CHA, MOVE, SAF, Save the Children, CAF, Cordaid, IMC, HealthNet TPO, AHDS, OHPM, BRAC, AADA, ACTD$, ACTD AFN, ACTD EU, CAF1, PU-AMI 1, AKHS, AKHS1, AFGA, SM MoD, MoE, MoHE, MoI, MoPH Household

Table A.2: Financing Schemes, by Functions, HC x HF

HC.1.3. 3 HC.2.1 HC.2.2

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9,313,85 5

6,216,51 7

0

0

723,186

100,265,1 4,103,514 99

0

1,458,19 5

25,74 8

HF.2.2.1

0

HF.2.2.2

HF.3.1

98,409 36,290,79 0

165,997,7 88

2,545,80 76,368,08 1 6

165,997,7 88

HF All HF .4.3

Other countries of the world financing schemes

51,313,80 17,493,92 5 8

HF.2. 2

NPISH financing schemes (including development agencies) NPISH financing schemes (excluding HF.2.2.2)

6,216,51 7

HF.1. 1.1.5

Ministry of Education

9,313,85 5

Ministry of Higher Education

42,170,93 17,493,92 0 8

Ministry of Interior Affairs

HF.1.1.1 .4

Ministry of Defense

HF.1.1.1 .3

Out-of-pocket, excluding cost sharing

General inpatient curative care General inpatient curative care Specialized outpatient curative care Inpatient rehabilitative care Day rehabilitative care General outpatient curative care

HF.1.1.1. 2

Resident foreign agencies’ schemes

HC.1.1. 1

HF.1.1.1.1 Ministry of Public Health

Healthcare functions

Government schemes

Reported currency: US Dollar Financing HF.1. schemes 1

277,582,2 16 0

329,249,7 79

4,955,073

5,678,259

3,619,576

3,619,576

230,543

230,543

1,090,01 28,591,73 5 2

185,199,9 22

0

320,734,3 26

HC.1.1 +HC.2. 1 HC.1.2 +HC.2. 2 HC.1.3 +HC.2. 3 HC.4.1 HC.4.3 HC.4.n ec HC.5.1. 1 HC.5.2. 1 HC.5.2. 2 HC.5.2. 3

Inpatient curative and rehabilitative care Day curative and rehabilitative care Outpatient curative and rehabilitative care Laboratory services Patient transportation Unspecified ancillary services (n.e.c.) Prescribed medicines Glasses and other vision products Hearing aids Other orthopedic appliances and prosthetics (excluding glasses and hearing aids)

32 | P a g e

50,591,39 17,493,92 2 8

9,313,85 5

6,216,51 7

2,545,80 64,469,86 1 8

722,413

165,997,7 88

11,898,21 7

100,988,3 4,103,514 85

1,458,19 5

25,74 8

1,090,01 33,546,80 5 5

12,620,63 0 185,199,9 22

1,367,202

326,412,5 85 1,367,202

40,000 150,000

316,629,1 49

34,386

2,468

646,873

249,614,7 53

249,654,7 53 186,854

821,447,6 12 6,331,786

821,447,6 12 6,331,786

1,948,242

1,948,242 646,873

HC.6.1. 1.nec

HC.6.1. 2 HC.6.1. 3 HC.6.1. nec HC.6.2 HC.6.4

HC.6.5. 1 HC.6.6

HC.6.7

Other and unspecified addictive substances information, education, and communicatio n (IEC) programs (n.e.c.) Nutrition IEC programs Safe sex IEC programs Other and unspecified IEC programs (n.e.c.) Immunization programs Healthy condition monitoring programs Planning & management Preparing for disaster and emergency response programs Food distribution for preventing malnutrition

33 | P a g e

201,973

201,973

7,832,990

7,832,990

78,349

3,110,000

78,349 3,311,518

3,311,518

54,267,70 8 79,409

57,377,70 8 79,409

5,805

5,805

5,662,328

5,662,328

32,149,28 4

32,149,28 4

HC.6.8

HC.6.9 HC.6.n ec HC.7

HC.9

Preventive care of HIV, TB, malaria, and vaccinepreventable disease Prevention and public health services Unspecified preventive care (n.e.c.) Administration and public health programs Other healthcare services not classified elsewhere (n.e.c.)

1,480,000

650,000

47,016,18 1

34 | P a g e

0

0

0

122,8 07

0

6,482,142

1 21,004,65 1

21,714,63 6

966

966

11,338 38,640,07 8

50,000

206,165,5 21,597,44 74 2

All HC Memorandum items HCR.2. Community 3 mobilization HCR.2. Education and 4 training of health personnel HCR.2. Other food, 5 hygiene, and drinking water control

59,98 4

5,002,142

0

0

160,751

9,348,24 1

7,674,71 2

208,5 39

3,725,50 278,883,8 4 35

210,751

1,430,540, 103

1,958,143, 950

189,276 177,31 4

754,270

2,163 ,561 665

1,839,958

570,809

85,790,40 4

189,276 1,0 92, 828

6,027,932

571,473

HCR.2. 6

Other research 277,5 199,686 477,187 and 01 development in health Data sources used: Donors USAID, EU, UNFPA, WHO, UNICEF, WFP, JICA, UNODC, MSF, ISAF, Emergency, ARCS, CIDA, TIKA, IFRC, GAVIHSS, CIDA1, EU1, EU2, AKDN , HANDICAP, SOZO Int, IOM, Italian cooperation, Medair, IAM, ICRC NGOs SDO, SCA, BDN, PU-AMI, HADAAF, CHA, MOVE, SAF, Save the Children, CAF, Cordaid, IMC, HealthNet TPO, AHDS, OHPM, BRAC, AADA, ACTD$, ACTD AFN, ACTD EU, CAF1, PU-AMI 1, AKHS, AKHS1, AFGA, SM Govern MoD, MoE, MoHE, MoI, MoPH ment sources Househ Household olds

35 | P a g e

HP.2.2 HP.3.4. 1 HP.4.1 HP.4.2 HP.4.9 HP.5.1

Other providers of ancillary services Pharmacies

36 | P a g e

9,348,241

7,674,712

8,326,264

HF.2.2.2

HF.3.1

Out-of-pocket, excluding cost sharing

21,597,442

HF.2.2.1

Resident foreign agencies’ schemes

43,736,439 446,703

HF.1.1. 1.5

Ministry of Education

HF.1.1.1.4

NPISH financing schemes (excluding HF.2.2.2)

HP.1.3

General hospitals Mental health hospitals Specialized hospitals (other than mental health hospitals) Mental health and substance abuse facilities Family planning centers All other ambulatory centers Providers of patient transportation and emergency rescue Medical and diagnostic laboratories

HF.1.1.1.3

Ministry of Higher Education

HP.1.1 HP.1.2

HF.1.1.1.2

Ministry of Interior Affairs

Healthcare providers

HF.1.1.1.1

Ministry of Defense

Reported currency: US Dollar Financing schemes

Ministry of Public Health

Table A.3: Financing Schemes, by Healthcare Providers, HP x HF

2,447,392

36,144,385

121,493

40,420,527 148,037

612,804,997

735,703,851 594,740 46,918,041

3,320,000

3,320,000 2,031,584

97,981,623

All HF

0

0

0

25,748

1,066,932

67,855,373

2,031,584 330,674,651

497,604,327

30,000

30,000

788,364

788,364

700,000

2,468

702,468 478,780,427

478,780,427

HP.5.2

Retailers and other suppliers of durable medical goods and medical appliances

HP.6

Providers of preventive care Government health administration agencies Community health workers (or village health workers, community health aides, etc.) Other countries of the world Unspecified healthcare providers (n.e.c.)

HP.8.3

HP.9 HP.nec

All HP Data sources used: Donors NGOs Govern ment sources Househ olds

877,416

3,110,000 47,016,181

0

0

0

59,984

78,350

80,925,068

122,80 7

11,338

38,661,545

660,000

50,000 206,165,57 4

21,597,442

9,348,241

7,674,712

208,53 9

3,725,504

8,280,028

9,157,444

84,173,402 0

85,811,871

2,185,880

2,845,880

9,525,544

9,525,544

106,008

156,008

278,883,835

1,430,540,1 03

1,958,143,9 50

USAID, EU, UNFPA, WHO, UNICEF, WFP, JICA, UNODC, MSF, ISAF, Emergency, ARCS, CIDA, TIKA, IFRC, GAVIHSS, CIDA1, EU1, EU2, AKDN, HANDICAP, SOZO Int, IOM, Italian cooperation , Medair, IAM, ICRC SDO, SCA, BDN, PU-AMI, HADAAF, CHA, MOVE, SAF, Save the Children, CAF, Cordaid, IMC, HealthNet TPO, AHDS, OHPM, BRAC, AADA, ACTD$, ACTD AFN, ACTD EU, CAF1, PU-AMI 1, AKHS, AKHS1, AFGA, SM MoD, MoE, MoHE, MoI, MoPH

Household

37 | P a g e

Reported currency: US Dollar Healthc HP.1 HP.2. 2 are .1 provide rs

Heal thca re func tions HC. 1.1.1

HC. 1.1.2

HC. 1.2.2

HC. 1.3.1 General inpatient curative care Speciali zed inpatient curative care Speciali zed day curative care General outpatie nt curative care

38 | P a g e 607,50 7.6 0.0 277,58 2,216.2

0.0 0.0 35,427, 356.9

12,3 90,0 87.4 0.0 0.0 12,390, 087.4

10,5 30,7 12.3 307,43 8,788.1 0.0

3,320, 000.0

HP.4. 2 HP.4. 9 Other providers of ancillary services

HP.5.2 HP.7. 1 HP.8.2 HP.8. 3

All other industries as secondary providers of healthcare Community health workers (or village health workers, community health aides, Other industries n.e.c. etc.)

HP.6

Government health administration agencies

Providers of preventive care

HP.5 .1 Retail sellers and other suppliers of durable medical goods and medical appliances

Pharmacies

HP.4.1

Medical and diagnostic laboratories

HP.3.4 .9

Providers of patient transportation and emergency rescue

All Other ambulatory centers

276, 974, 708. 6 32,1 07,3 56.9 Mental health and substance abuse facilities

General hospitals

495,8 04.6

HP.9 HP.ne c Unspecified healthcare providers (n.e.c.)

HP.8 .9 Other countries of the world

Table A.4: Healthcare Providers, by Functions, HC x HP

1,83 4,72 0.0

All HP

320,38 8,973.0

HC. 1.3.3

HC. 2.1 HC. 2.2 HC. 2.3

HC. 1.1+ HC. 2.1 HC. 1.2+ HC. 2.2 HC. 1.3+ HC. 2.3

Speciali zed outpatie nt curative care Inpatient rehabilit ative care Day rehabilit ative care Outpatie nt rehabilit ative care Inpatient curative and rehabilit ative care Day curative and rehabilit ative care Outpatie nt curative and

39 | P a g e

563, 186. 4

5,115,0 73.0

0.0

5,678,2 59.4

3,61 9,57 6.0

0.0

0.0

3,619,5 76.0

0.0

0.0

0.0

230,54 3.0

110, 000. 0

235,35 3.0

0.0

345,35 3.0

607,50 7.6

0.0

316,62 9,149.0

0.0

12,620, 630.4

312, 701, 641. 4

3,320, 000.0

12,3 90,0 87.4

0.0

11,2 03,8 98.7

312,78 9,214.2

230,543 .0

230,543 .0

0.0

495,8 04.6

1,83 4,72 0.0

326,41 2,585.5

HC. 4.1 HC. 4.3 HC. 4.ne c HC. 5.1.1 HC. 5.2.1

HC. 5.2.2 HC. 5.2.3

rehabilit ative care Laborato ry services Patient transport ation Unspecif ied ancillary services (n.e.c.) Prescrib ed medicin es Glasses and other vision products Hearing aids Other orthoped ic applianc es and prostheti cs (excludi ng

40 | P a g e

0.0

28,838. 0

104, 140, 023. 9 34,3 86.0

145,47 4,729.3

342, 667, 184. 9 0.0

0.0

0.0

0.0

0.0

0.0

0.0

0.0

788,3 64.4

550,0 00.0

0.0

30,000. 0

0.0

152,4 68.4

478, 780, 427. 4

1,367,2 02.4 10,00 0.0

249,65 4,753.2

0.0

186,85 4.4

0.0

821,44 7,612.3

6,331,7 85.9

0.0

6,331,7 85.9

1,948,2 41.8 646,873 .0

0.0

1,948,2 41.8 646,87 3.0

0.0

glasses and hearing aids) HC. 6.1.1 .nec

HC. 6.1.2 HC. 6.1.3 HC. 6.1.n ec

HC. 6.2

Other and unspecif ied addictiv e substanc es IEC program s (n.e.c.) Nutritio n IEC program s Safe sex IEC program s Other and unspecif ied IEC program s (n.e.c.) Immuniz ation program s

41 | P a g e

0.0

0.0

201,97 2.6

0.0

0.0

413,65 5.7

5,525,8 00.3

0.0

0.0

0.0

78,348. 6

0.0

0.0

0.0

3,127,9 68.5

0.0

0.0

158,95 0.5

57,218, 757.4

0.0

201,97 2.6

1,89 3,53 4.0

7,832,9 89.9 78,348. 6

101, 630. 5

81,91 9.0

3,311,5 18.0

57,377, 707.9

HC. 6.4

HC. 6.5.1 HC. 6.6

HC. 6.7

HC. 6.8

Healthy conditio n monitori ng program s Planning & manage ment Preparin g for disaster and emergen cy response program s Food distributi on for preventi ng malnutri tion Preventi ve care of HIV,TB, malaria, and vaccinepreventa

42 | P a g e

79,4 09.2

0.0

0.0

79,409. 2

0.0

0.0

5,805. 0

5,805.0

0.0

131,00 6.3

5,525,8 00.3

5,521. 0

5,662,3 27.5

0.0

29,589, 769.0

315,57 3.0

0.0

0.0

3,758,9 32.2

2,723,2 09.9

0.0

100,5 76.3

2,14 3,36 6.0

32,149, 284.3

6,482,1 42.1

ble disease HC. 6.9

HC. 6.ne c HC. 7.1.1 HC. 7.1.2

HC. 7.1.3

HC. 7.1.4

Preventi on and public health services Unspecif ied preventi ve care (n.e.c.) Planning & manage ment Monitori ng & evaluati on (M&E) Procure ment & supply manage ment Leaders hip, manage ment, and administ rative

43 | P a g e

0.0

4,492,7 73.8

9,455,9 71.3

10,14 1.0

2,239, 498.7

3,55 1,32 7.9

0.0

0.0

0.0

0.0

0.0

538,3 82.0

538,38 2.0

0.0

0.0

434,6 23.0

434,62 3.0

0.0

0.0

806,0 42.0

806,04 2.0

0.0

0.0

41,15 0,240. 9

41,150, 240.9

965. 5

22,28 7.8

21,714, 636.1

965.5

HC. 7.1.5 HC. 7.1.6

HC. 7.1.7 HC. 7.1.8 HC. 7.1.9

HC. 7.1.n ec

HC. 9

Adminis tration of TB program Adminis tration of malaria program Adminis tration of CH program Adminis tration of RH program Adminis tration of HIV/AI DS program Other governa nce and health system administ ration (n.e.c.) Other healthca re services

44 | P a g e

0.0

0.0

363,4 76.8

363,47 6.8

0.0

0.0

322,1 65.2

322,16 5.2

0.0

0.0

748,7 75.8

748,77 5.8

0.0

0.0

2,904, 269.3

2,904,2 69.3

0.0

0.0

1,948. 9

1,948.9

0.0

0.0

38,52 0,480. 0

38,520, 480.0

0.0

158,95 0.5

0.0

51,80 0.9

210,75 1.4

not classifie d elsewher e (n.e.c.) All HC

Memorandum items HCR Commu .2.3 nity mobiliza tion HCR Educatio .2.4 n and training of health personne l HCR Other .2.5 food, hygiene, and drinking water control HCR Other .2.6 research and develop ment in health

45 | P a g e

783, 216, 631. 5 0.0

3,320, 000.0

497,60 4,327.0

30,000. 0

788,3 64.4

702,4 68.4

478, 780, 427. 4

9,157,4 43.7

84,173, 401.9

85,81 1,871. 0

2,845, 879.6

9,52 5,54 3.9

156,0 07.7

1,958,1 43,950. 0

0.0

0.0

0.0

38,8 36.1

496,6 21.4

0.0

0.0

0.0

0.0

189,2 76.0 88,232. 5

189,27 6.0

3,149, 261.9

931, 028. 5

570,8 08.6

664. 7

199, 685. 6

693, 673. 0

6,027,9 31.6

571,47 3.3

277, 501. 0

477,18 6.6

Table A.5: Financing Agents, by Financing Sources, HF x FA

HF.1.1.1.2 HF.1.1.1.3 HF.1.1.1.4 HF.1.1.1.5 HF.2.2.1

HF.2.2.2

HF.3.1

All HF

46 | P a g e

Ministry of Public Health Ministry of Defense Ministry of Interior Affairs Ministry of Higher Education Ministry of Education NPISH financing schemes (excluding HF.2.2.2) Resident foreign agencies’ schemes Out-of-pocket, excluding cost sharing

21,597,44 2

FA.5

FA.7

358,338

206,165,574 21,597,442

9,348,24 1

9,348,241 7,674,71 2

7,674,712 208,539

208,539 3,725,50 4

67,193

3,725,504

2,055,26 1

276,761,38 1 1,430,540,10 3

203,398,98 4

24,072,88 7

All FA

Other countries of the world

FA.4

Household s

FA.1.1. 8

Ministry of Education

FA.1.1.7 Ministry of Higher Education

2,475,445

Ministry of Interior Affairs

203,331,79 1

FA.1.1.6

Nonprofit institutions serving household s (NPISH)

HF.1.1.1.1

Ministry of Defense

Financing schemes

FA.1.1.5

Ministry of Public Health

Reported currency: US Dollar Financing FA.1.1.1 agents

9,348,24 1

7,674,71 2

208,539

6,139,10 2

1,430,540,10 3

278,883,835

1,430,540,10 3 276,761,38 1

1,958,143,95 0

Table A.6: Financing Sources, by Diseases, FS X DIS Reported currency: US Dollar Non-disease-specific expenditures reported separately

TB treatment (general)

DIS.1.3

Malaria

DIS.1.7

Vaccine-preventable diseases

DIS.2.1

Maternal conditions

DIS.2.2

Perinatal conditions

DIS.2.3

Contraceptive management (family planning)

DIS.2.4

SBA

DIS.7.1

ARI

DIS.7.2

Diarrheal disease

DIS.7.3

Malnutrition (nutritional deficiencies)

DIS.7.4

Anemia

47 | P a g e

FS.8.1

All FS Households’ out-of-pocket

DIS.1.2.3

FS.7.1.4 Direct foreign financial transfer

HIV/AIDS

FS.6.3 Other revenues from NPISH n.e.c.

Classification of diseases / conditions DIS.1.1.1.1

FS.2

Transfers distributed by government from foreign origin

Central government revenue

Revenues of healthcare financing schemes FS.1.1.1

1,480,000

78,349

2,467,044

4,025,392

313,148

199,353

806

18,158,951

2,696,541

21,368,799

86,199

1,701,682

4,647

9,534,286

5,640,387

16,967,201

770,698

770,698

697,618

5,292,442

57,721

8,545,440

44,239,469

58,832,690

1,215,935

8,843,110

98,905

4,123,682

75,804,044

90,085,675

1,132,664

8,581,442

96,024

5,025,149

73,596,160

88,431,439

1,303,493

9,491,609

106,160

4,843,153

81,364,643

97,109,058

2,690,216

26,813,457

281,491

7,083,140

246,926,222

283,794,526

2,296,284

8,036,760

70,606

3,320,179

83,217,639

96,941,469

819,049

4,076,961

39,224

52,163,493

39,936,930

97,035,658

366,002

1,603,935

18,138

448,290

13,901,497

16,337,862

DIS.7.5

Child immunization

DIS.7.6

Other

DIS.8

Governance, management, and administration

DIS.9

All diseases of IPD & OPD

DIS.10

Health promotion lifesaving through RMNCH

DIS.nec

Other and unspecified diseases/conditions (n.e.c.)

All DIS

48 | P a g e

2,127,764

7,475,741

72,551

50,310,033

31,839,21 5

58,143,182

2,800,88 3

74,825,357

44,466,27 0

4,730,000

5,948,349

55,144,619

7,565,134

795,841

25,440,191

33,801,166

47,839

47,839

5,828,561

6,638,561

210,000

600,000

97,128,99 2

147,865,51 6

3,725,50 4

278,883,83 5

59,986,089 763,216,572

1,430,540,10 3

930,825,209

1,958,143,95 0

HK.1.1.1.2 HK.1.1.2.1 HK.1.1.2.2 HK.1.1.2.3 HK.1.1.2.4 HK.1.1.3.1 HK.1.nec

HK.2.2 HK.nec

Residential and non-residential buildings Other structures Medical equipment Transport equipment ICT equipment Machinery and equipment n.e.c. Computer software and databases Unspecified gross capital formation (n.e.c.) Other nonproduced, nonfinancial assets Unspecified gross fixed capital formation (n.e.c.)

All HK

49 | P a g e

502,961 1,227,916 2,418,034

532,662

21,706

2,303,467

3,684,573

11,189

HP.nec

00,000 24,505

14,063

500,253

1,067,641

13,587

234,583

92,915

26,700 11,000

1,468,979

138,219

4,137,584

13,675,804 7,013,572

154,773

7,197 1,999

1,999

2,230,912 593,103

1,067,537

49,143

4,743,749

140,760 377,183

796,865

140,760 10,522

301,931

27,915

216,201

34,842

29,653

43,616

532,662

21,706

2,314,656

13,210,754

1,795,113

43,616

41,335

4,667,405

All HP

Unspecified healthcare providers (n.e.c.)

HP.8 Rest of economy

HP.7.4

Providers of healthcare system administratio n and Governance, financing technical assistant administrativ e

HP.7

3,566,022

2,197,015 9,925 1,470,839

HP.6

3,063,061

4,322,864

264,076 380,196

HP.4

Providers of preventive care

HP.3.4.9

Providers of ancillary services

HP.3

All other ambulatory centers

HP.1.3

Providers of ambulatory healthcare

HP.1.2

Specialized hospitals (other than mental health hospitals)

HK.1.1.1.1

HP.1.1 General hospitals

Capital Account

HP.1 Hospitals

Healthcare providers

Mental health hospitals

Table A.7: Capital Expenditure, by Providers, HK x HP

12,466

3,287,646

24,505

2,577,665

1,518,524

53,801

370,975

5,249,159

80,795

33,856,452

Annex B: Classification of Health Expenditure Annex. Major Contributors to Afghanistan’s Health Sector

Donor Name

Total Expenditure (Amount in USD)

Total Expenditure (Percentage)

Households MoPH as government revenue expenditure USAID UNICEF World Bank WHO MoD MSF EU JICA WFP Multiple donors ISAF CIDA GAVIHSS ICRC UNFPA MoI Emergency MoHE AKDN TIKA ARCS IFRC Italian cooperation MoE

1,430,540,103 99,581,150 80,671,944 49,706,104 41,060,000 35,539,545 29,243,500 25,954,110 25,534,092 24,464,213 22,462,584 21,359,934 16,367,422 15,040,546 10,145,662 10,074,229 9,698,664 9,348,241 9,276,001 7,674,713 6,439,470 4,423,473 4,296,977 2,460,168 340,788 296,772

71.81% 5.00% 4.05% 2.50% 2.06% 1.78% 1.47% 1.30% 1.28% 1.23% 1.13% 1.07% 0.82% 0.76% 0.51% 0.51% 0.49% 0.47% 0.47% 0.39% 0.32% 0.22% 0.22% 0.12% 0.02% 0.01%

Total Health Expenditure

1,992,000,405

100%

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Glossary  Current Health Expenditure (CHE): CHE reported in the SHA is the sum of healthcare goods and services for final consumption by resident. When broken down by providers (as in SHA table HC x HP), it also represents the value of that part of the output of health providers consumed by households; NPISH and general government are valued at market prices. SHA calls “provision” the value of the health providers’ output used as final consumption. The same information would be recorded in SNA in the supply-and-use tables and the production account―the account showing output as a resource and intermediate consumption as use. The value of goods and services consumed as intermediate consumption by health providers is also recorded in the SHA HC x FP tables, which make use of the factors of provision classification.  Total Health Expenditure (THE): THE consists of all recurrent and capital expenditures incurred for a period of time and is reported in the SHA.1 methodology.  Gross Domestic Product (GDP): A statistic that refers to the total market value of goods and services produced within a given period, after deducting the cost of goods and services used in the process of production but before deducting an allowance for the consumption of fixed capital.  System of Health Accounts (SHA) (OECD, 2011): A standardized framework for reporting and classifying health expenditure, developed by OECD and endorsed by WHO for international reporting by countries.  Financing Scheme: Health care financing schemes are the main types of financing arrangements through which people obtain health services. Health care financing schemes includes direct payments by households for services and goods and third party financing arraignments.  Financing Sources: A term used for the entities that provide resources to

“financing agents” for pooling and distribution. In the case of households in Afghanistan, the financing source and agent are the same. Most financing sources are defined clearly by their names.

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References

(OECD), (2011). System of Health Accounts. 2011 (SHA2011), Organization of Economics and Coordination Development. Organization of Economics and Coordination Development. Central Statistical Organization, C. (2014). CSO Statistical year book. Kabul, Afghanistan. MoPH. (2010). Basic Package of Health Services (BPHS) 2010. Kabul: Ministry of Public Health. MoPH. (2016). National Health Strategy 2016–2020. Kabul, Afghanistan: Government Islamic Republic of Afghanistan, Ministry of Public Health. OECD, E. W. (2011). A System of HEalth Accounts,. OECD. WHO. (2003). National Health Accounts Production Guide to produce National Health Accounts with special applications for low and middle- income countries . Geneva, Switzerland: WHO. WHO. (n.d.). Nationial Health Accounts Production Tool, User Guide. World Health Organization, USAID, World Bank.

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Afghanistan third round of National Health Accounts, including disease accounts, covers the estimates of health spending for the year 2014.