afghanistan national health accounts with disease … · summary of findings in comparison with...

Islamic Republic of Afghanistan

Ministry of Public Health

Afghanistan National Health Accounts

$1.99bn

Out of Pocket

1.43bn (72%)

Rest of the World

0.46bn (23%)

Government

0.10bn (5%)

SHA.2011

with Disease Accounts, 2014

Afghanistan National Health Accounts

with Disease Accounts, 2014

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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

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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 ARI ARCS

Afghanistan Financial Management Information System Acute Respiratory Infection Afghan Red Crescent Society

ATM BPHS

HIV/AIDS, Tuberculosis, and Malaria Basic Package of Health Services

CH CHE CIDA CSO EMIS EPHS

Child Health Current Health Expenditure Canadian International Development Agency Central Statistics Organization Expenditure Management Information System Essential Package of Hospital Services

EU FA

European Union Financing Agent

GAVI The Global Alliance for Vaccines and Immunization GCMU Grants and Contracts Management Unit GDP GIRoA

Gross Domestic Product Government of the Islamic Republic of Afghanistan

HEFD HH ICD

Health Economics and Financing Directorate Household International Classification of Diseases

ICRC IEC

International Committee of the Red Cross Information, Education, and Communication

IFRC International Federation of Red Cross and Red Crescent Societies IOM IPD ISAF

International Organization for Migration Inpatient Department International Security Assistance Force

JICA Japan International Cooperation Agency

MoD Ministry of Defense

http://www.iom.int/key-migration-terms

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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 NPISH

National Health Accounts Non-Profit Institutions Serving Households

NRVA NDS

National Risk and Vulnerability Assessment National Directorate of Security

OECD Organization for Economic Cooperation and Development

OOP OPD RH SBA SHA

Out of Pocket Outpatient Department Reproductive Health Skilled Birth Attendant System of Health Accounts

TB THE

Tuberculosis 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 USD

United States Agency for International Development 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:

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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 Low-

and 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 revenue-raising 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.

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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 cross-verify 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

𝑇𝑜𝑡𝑎𝑙 𝑤𝑒𝑖𝑔ℎ𝑡𝑒𝑑 𝑢𝑡𝑖𝑙𝑖𝑧𝑎𝑡𝑖𝑜𝑛 𝑓𝑜𝑟 𝑎𝑙𝑙 𝑠𝑒𝑟𝑣𝑖𝑐𝑒𝑠= % 𝑢𝑡𝑖𝑙𝑖𝑧𝑎𝑡𝑖𝑜𝑛 𝑓𝑜𝑟 𝑑𝑖𝑠𝑒𝑎𝑠𝑒𝑠 𝑎𝑙𝑙𝑜𝑐𝑎𝑡𝑖𝑜𝑛

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

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.

-

500,000,000

1,000,000,000

1,500,000,000

2,000,000,000

2,500,000,000

2008-2009 2011-2012 2014

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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 Average exchange rate (USD: AFN) 1:50 1:47 1:57 Total government health expenditure (USD) 63,892,239 84,148,093 97,128,992

Current Health Expenditure (CHE) 1,958,143,950 THE 1,043,820,810 1,500,975,945 1,992,000,402 THE per capita (USD) 41.73 55.59 THE as % of GDP 10.0% 8.0% 9.5% Government health expenditure as % of total government expenditure 4.0% 4.2% 4.3%

Financing Source as a % of THE Central government 6.0% 5.6% 5.0% 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 THE 75.0% 73.3% 71.8%

Total HH (OOP) spending per capita (USD) 31 41 51

Financing Agent Distribution as a % of THE Central government 11.0% 11.8% 12.4% Household 75.0% 73.3% 71.8% NGOs 5.0% 0.3% 0.3% Other countries in the world 8.0% 14.6% 15.5%

Provider Distribution as a % of THE Hospitals 29.0% 24.0% 39.8% Outpatient care centers 32.0% 25.0% 26.4% Retailers and other providers of medical goods 28.0% 26.0% 24.5%

Other 11.0% 25.0% 9.2% Function Distribution as a % of THE

Curative care 59.0% 37.0% 32.7% Pharmaceuticals 28.0% 26.0% 41.7% Prevention and public health programs 5.0% 5.0% 6.8% Health administration 5.0% 6.0% 4.3% Capital formation 2.0% 1.0% 1.7% Ancillary services - 24.0% 12.6% Other 1.0% 1.0% 0.2%

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70.9

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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

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.

9.3

34

7

3

56

4

0

1

2

3

4

5

6

7

8

9

10

Afghanistan Pakistan Kazakhstan Tajikistan Bangladesh India Nepal Sri Lanka

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Figure 3: Private Health Expenditure as a Percentage of THE, 2014

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 Amount Percentage

Transfers from government domestic revenue (allocated to health purposes)

97,128,992 5.0%

Transfers distributed by government from foreign origin 147,865,516 7.6%

Private (household OOP) 1,430,540,103 73.1% Other revenues from nonprofit institutions serving households (NPISH) not elsewhere classified

3,725,504 0.2%

Direct foreign transfers 278,883,835 14.2%

Total 1,958,143,950 100%

7259

40

65

46

71

4760

44

78

0

10

20

30

40

50

60

70

80

90

14 | P a g e

Figure 4: Breakdown of Financing Source

Household OOP Health Expenditure

Using data obtained from the AHS 2015, this round of NHA showed that approximately three-quarters 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 Amount Percentage

Outpatient 192,688,689 13.5%

Inpatient 140,834,957 9.8%

Retailers and other providers of medical goods and medicines 829,727,640

58.0%

Vision products 6,331,786 0.4% Hearing products 1,948,242 0.1% Medicines 821,447,612 57.4% Diagnostics 267,288,818 18.7%

Total HH expenditure 1,430,540,103 100.0%

5%8%

73%

0%

14%

Transfers from governmentdomestic revenue(allocated to health purposes)

Transfers distributed bygovernment from foreign origin

Private (Household Out of Pocket)

Other revenues from NPISH n.e.c.

Direct foreign transfers

15 | P a g e

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 Percentage

Transfers from government domestic revenue 97,128,992 18.47%

(allocated to health purposes) MoPH 84,546,008 87.0% MoD 2,519,643 2.59% MoI 2,180,089 2.24% MoHE 7,674,712 7.90% MoE 208,539 0.21% Transfers distributed by government from foreign origin 147,865,516 28.12%

Direct donors’ expenditures on health 277,145,437 52.70%

Other domestic revenue 3,725,504 0.71%

Total 527,603,846 100.00%

13%

10%

58%

19%OPD

IPD

Retailers & other providersof medical goods &Medicine

Diagnosis

16 | P a g e

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.

16%

1%0%

1%

0%

28%

53%

1%

Ministry of Public Health

Ministry of Defense

Ministry of Interior Affairs

Ministry of Higher Education

Ministry of Education

Transfers distributed by governmentfrom foreign origin

Donors Expenditure on health as public

Other Domestic Revenue

17 | P a g e

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 Amount Percentage

Hospitals 783,216,631 40.0%

Outpatient care centers 499,635,911 25.5%

Residential and long-term care 3,320,000 0.2%

Retailers and other providers of medical goods/Medicine 487,937,871 24.9%

Provision and administration of public health programs 84,173,402 4.3%

General health administration 85,811,871 4.4%

All others 14,048,264 0.7%

Total 1,958,143,950 100%

13%

73%

0%

14%

Central Government

Households

Non-Provite Institutioniserving households

Rest of the World (RoW)

18 | P a g e

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 Percentage

Curative 651,466,893 33.27%

Inpatient curative care 325,399,660 49.95%

Outpatient curative care 326,067,232 50.05%

Rehabilitation care 4,195,472 0.21%

Ancillary services 251,208,810 12.83%

Medical goods dispensed to outpatients 830,374,513 42.41%

Prevention and public health services 134,897,107 6.89%

Health administration of public health programs 85,790,404 4.38%

All others 210,751 0.01%

Total 1,958,143,950 100%

40.0%

25.5%

0.2%

24.9%

4.3%

4.4%0.7% Hospitals

Outpatient care centers

Residential and long termcare

Retialers & other providers ofmedical goods/ medicine

Provision and administrationof public health programs

General healthadministration

All others

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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

Gross

capital

formation

Non-

produced

non-financial

assets

Unspecified gross

fixed capital

formation (n.e.c.)

All

General government

7,824,785.6 5,846.5 7,830,632.1

MoPH 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

33%

0%

13%

43%

7%4%

0% Curative

Rehablitation care

Ancillary services

Medical goods dispensed tooutpatients

Prevention and publichealth services

Health administration ofpublic health programs

All others

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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 Code Disease categories Amount Percentage

DIS.1 Infectious and parasitic diseases 42,361,392 2.2%

DIS.1.1.1.1 HIV/AIDS 4,025,392 0.2% DIS.1.2 TB 21,368,799 1.1% DIS.1.3 Malaria 16,967,201 0.9% DIS.2 Reproductive health 334,458,863 17.1%

DIS.2.1 Maternal conditions 58,832,690 3.0% DIS.2.2 Perinatal conditions 90,085,675 4.6% DIS.2.3 Contraceptive management (family

planning) 88,431,439 4.5%

DIS.2.4 Skilled birth attendant (SBA) 97,109,058 5.0% DIS.7 Child health diseases 494,109,515 25.2%

DIS.7.1 Acute respiratory infection (ARI) 283,794,526 14.5% DIS.7.2 Diarrheal diseases 96,941,469 5.0% DIS.7.3 Malnutrition (nutritional deficiencies) 97,035,658 5.0% DIS.7.4 Anemia 16,337,862 0.8% DIS.7.5 Child immunization 60,756,786 3.1%

DIS.nec Other diseases not classified above 1,026,457,394 52.4%

Total 1,958,143,950 100%

21 | P a g e

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 expenditure-by-disease categories and accompanying financing sources, thus identifying the key players and how much each of them spent on each disease.

2.2%

17.1%

25.2%

3.1%

52.4%

Infectious and parasiticdiseases

Reproductive health

Child health diseases

Child immunization

Other disease notclassified above

22 | P a g e

Table 9: Disease Expenditure, by Financing Sources

Disease categories

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

Private

Expenditure on

Health

(households’ OOP

expenditures)

Total expenditure

on all diseases

Infectious and parasitic

diseases

399,347 3,381,036 83,802 30,160,280 8,336,927 42,361,392

HIV/AIDS 1,480,000 78,349 2,467,044 4,025,392 TB 313,148 199,353 806 18,158,951 2,696,541 21,368,799 Malaria 86,199 1,701,682 4,647 9,534,286 5,640,387 16,967,201 Reproductive health 4,349,710 2,208,602 358,809 22,537,425 275,004,316 334,458,863 Maternal conditions

697,618 5,292,442 57,721 8,545,440 44,239,469 58,832,690

Perinatal conditions 1,215,935 8,843,110 98,905 4,123,682 75,804,044 90,085,675 Family planning 1,132,664 8,581,442 96,024 5,025,149 73,596,160 88,431,439 SBA 1,303,493 9,491,609 106,160 4,843,153 81,364,643 97,109,058 Child health diseases 6,171,551 0,531,114 409,459 63,015,103 383,982,288 494,109,515

ARI 2,690,216 6,813,457 281,491 7,083,140 246,926,222 283,794,526 Diarrheal disease 2,296,284 8,036,760 70,606 3,320,179 83,217,639 96,941,469 Nutritional program 819,049 4,076,961 39,224 52,163,493 39,936,930 97,035,658 Anemia 366,002 1,603,935 18,138 448,290 13,901,497 16,337,862 Immunization 2,127,764 7,475,741 72,551 51,080,730 60,756,786

Other diseases not classified

above 4,080,619 4,269,024 800,883 12,090,297 763,216,572 1,026,457,394

Total

97,128,992 47,865,516 3,725,504 278,883,835 1,430,540,103 1,958,143,950

23 | P a g e

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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Table 10: Disease Expenditure, by Providers

Healthcare providers

Classification of diseases /

conditions Hos

pita

ls

Res

iden

tial l

ong-

term

car

e fa

cilit

ies

Prov

ider

s of

ambu

lato

ry

heal

thca

re

Prov

ider

s of

anci

llary

serv

ices

Ret

aile

rs a

nd

othe

r pro

vide

rs

of m

edic

al g

oods

Prov

ider

s of

prev

entiv

e ca

re

Prov

ider

s of

heal

thca

re

syste

m

adm

inis

tratio

n an

d fin

anci

ng

Res

t of e

cono

my

Oth

er c

ount

ries

of th

e w

orld

Uns

peci

fied

heal

thca

re

prov

ider

s (n.

e.c.

)

Total

Infectious and parasitic diseases

17,856,620 5,827,502 0 2,045,654 13,340,650 2,538,103 752,863 0 0 42,361,392

HIV/AIDS and other

sexually transmitted

diseases (STDs)

344,409 2,142,487 1,171,384 367,113 4,025,392

HIV/AIDS and

opportunistic infections

(OIs)

344,409 2,142,487 1,171,384 367,113 4,025,392

HIV/AIDS 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)

14,705,458 803,605 146,118 3,976,377 1,737,241 21,368,799

Malaria 2,806,753 2,881,411 1,899,536 8,192,889 433,749 752,863 16,967,201 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)

2,424,661 42,096,380 43,835,441 74,958 88,431,439

SBA 2,797,685 44,537,505 48,462,515 988,348 1,500 321,505 97,109,058 Child health diseases 100,302,413 0 195,733,332 0 179,433,072 11,367,174 3,406,295 524,024 3,343,205 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 11,367,174 1,240,072 141,394 2,538,087 97,035,658

Anemia 457,940 7,441,690 8,280,028 102,211 19,556 36,437 16,337,862 Child immunization 0 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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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-

26 | P a g e

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.

27 | P a g e

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 NHA-related 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.

28 | P a g e

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.

29 | P a g e

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 Reported currency: US Dollar Financing

schemes

HF.1.1.1.1 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

Revenues of

healthcare

financing

schemes

Min

istry

of P

ublic

H

ealth

Min

istry

of D

efen

se

Min

istry

of I

nter

ior

Aff

airs

Min

istry

of H

ighe

r Ed

ucat

ion

Min

istry

of

Educ

atio

n

NPI

SH fi

nanc

ing

sche

mes

(exc

ludi

ng

HF.

2.2.

2)

Res

iden

t for

eign

ag

enci

es’ s

chem

es

Out

-of-

pock

et,

excl

udin

g co

st

shar

ing

FS.1.1.1 Central government revenue

84,546,008 2,519,643 2,180,089 7,674,712 208,539 97,128,992

FS.2 Transfers distributed by government from foreign origin

121,619,566 19,077,798 7,168,152 147,865,516

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

3,725,504 3,725,504

FS.7.1.4 Direct foreign financial transfer

278,883,835 278,883,835

FS.8.1 Households’ OOP

1,430,540,103 1,430,540,103

All FS 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 Data sources used:

Donors 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),

30 | P a g e

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)

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

Government sources

MoD, MoE, MoHE, MoI, MoPH

Households Household

31 | P a g e

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

Reported currency: US Dollar Financing

schemes

HF.1.1

HF.1.1.1.1 HF.1.1.1.2

HF.1.1.1.3

HF.1.1.1.4

HF.1.1.1.5

HF.2.2

HF.2.2.1 HF.2.2.2 HF.3.1 HF.4.3

All HF

Healthcare functions

Gov

ernm

ent s

chem

es

Min

istry

of P

ublic

Hea

lth

Min

istry

of D

efen

se

Min

istry

of I

nter

ior

Aff

airs

Min

istry

of H

ighe

r Ed

ucat

ion

Min

istry

of E

duca

tion

NPI

SH fi

nanc

ing

sche

mes

(inc

ludi

ng

deve

lopm

ent a

genc

ies)

N

PISH

fina

ncin

g sc

hem

es (e

xclu

ding

H

F.2.

2.2)

Res

iden

t for

eign

ag

enci

es’ s

chem

es

Out

-of-

pock

et, e

xclu

ding

co

st sh

arin

g

Oth

er c

ount

ries o

f the

w

orld

fina

ncin

g sc

hem

es

HC.1.1.1

General inpatient curative care

42,170,930

17,493,928

9,313,855

6,216,517

98,409 36,290,790

165,997,788

277,582,216


51,313,805

17,493,928

9,313,855

6,216,517

0 0 2,545,801

76,368,086

165,997,788

0 329,249,779

HC.1.3.3

Specialized outpatient curative care

723,186 4,955,073 5,678,259

HC.2.1 Inpatient rehabilitative care

3,619,576 3,619,576

HC.2.2 Day rehabilitative care

230,543 230,543

General outpatient curative care

100,265,199

4,103,514 0 1,458,195

25,748

0 1,090,015

28,591,732

185,199,922

0 320,734,326

32 | P a g e

HC.1.1+HC.2.1

Inpatient curative and rehabilitative care

50,591,392

17,493,928

9,313,855

6,216,517

2,545,801

64,469,868

165,997,788

316,629,149

HC.1.2+HC.2.2

Day curative and rehabilitative care

722,413 11,898,217

12,620,630

HC.1.3+HC.2.3

Outpatient curative and rehabilitative care

100,988,385

4,103,514 1,458,195

25,748

1,090,015

33,546,805

185,199,922

326,412,585

HC.4.1 Laboratory services

1,367,202 1,367,202

HC.4.3 Patient transportation

40,000 249,614,753

249,654,753

HC.4.nec

Unspecified ancillary services (n.e.c.)

150,000 34,386 2,468 186,854

HC.5.1.1

Prescribed medicines

821,447,612

821,447,612

HC.5.2.1

Glasses and other vision products

6,331,786 6,331,786

HC.5.2.2

Hearing aids 1,948,242 1,948,242

HC.5.2.3

Other orthopedic appliances and prosthetics (excluding glasses and hearing aids)

646,873 646,873

33 | P a g e

HC.6.1.1.nec

Other and unspecified addictive substances information, education, and communication (IEC) programs (n.e.c.)

201,973 201,973

HC.6.1.2

Nutrition IEC programs

7,832,990 7,832,990

HC.6.1.3

Safe sex IEC programs

78,349 78,349

HC.6.1.nec

Other and unspecified IEC programs (n.e.c.)

3,311,518 3,311,518

HC.6.2 Immunization programs

3,110,000 54,267,708

57,377,708

HC.6.4 Healthy condition monitoring programs

79,409 79,409

HC.6.5.1

Planning & management

5,805 5,805

HC.6.6 Preparing for disaster and emergency response programs

5,662,328 5,662,328

HC.6.7 Food distribution for preventing malnutrition

32,149,284

32,149,284

34 | P a g e

HC.6.8 Preventive care of HIV, TB, malaria, and vaccine-preventable disease

1,480,000 5,002,142 6,482,142

HC.6.9 Prevention and public health services

650,000 59,984

1 21,004,651

21,714,636

HC.6.nec

Unspecified preventive care (n.e.c.)

966 966

HC.7 Administration and public health programs

47,016,181

0 0 0 122,807

0 11,338 38,640,078

0 0 85,790,404

HC.9 Other healthcare services not classified elsewhere (n.e.c.)

50,000 160,751 210,751

All HC 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

Memorandum items HCR.2.3

Community mobilization

189,276 189,276

HCR.2.4

Education and training of health personnel

177,314

754,270 2,163,561

1,839,958 1,092,

828

6,027,932

HCR.2.5

Other food, hygiene, and drinking water control

665 570,809 571,473

35 | P a g e

HCR.2.6

Other research and development in health

277,501

199,686 477,187

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 Government sources


Households

Household

36 | P a g e

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

Reported currency: US Dollar Financing schemes HF.1.1.1.1 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

Healthcare providers

Min

istry

of P

ublic

H

ealth

Min

istry

of

Def

ense

Min

istry

of

Inte

rior A

ffai

rs

Min

istry

of H

ighe

r Ed

ucat

ion

Min

istry

of

Educ

atio

n

NPI

SH fi

nanc

ing

sche

mes

(e

xclu

ding

H

F.2.

2.2)

Res

iden

t for

eign

ag

enci

es’ s

chem

es

Out

-of-

pock

et,

excl

udin

g co

st

shar

ing

HP.1.1 General hospitals 43,736,439 21,597,442 9,348,241 7,674,712 121,493 40,420,527 612,804,997 735,703,851 HP.1.2 Mental health

hospitals 446,703 148,037 594,740

HP.1.3 Specialized hospitals (other than mental health hospitals)

8,326,264 2,447,392 36,144,385 46,918,041

HP.2.2 Mental health and substance abuse facilities

3,320,000 3,320,000

HP.3.4.1

Family planning centers

2,031,584 2,031,584

All other ambulatory centers

97,981,623 0 0 0 25,748 1,066,932 67,855,373 330,674,651 497,604,327

HP.4.1 Providers of patient transportation and emergency rescue

30,000 30,000

HP.4.2 Medical and diagnostic laboratories

788,364 788,364

HP.4.9 Other providers of ancillary services

700,000 2,468 702,468

HP.5.1 Pharmacies 478,780,427 478,780,427

37 | P a g e

HP.5.2 Retailers and other suppliers of durable medical goods and medical appliances

877,416 8,280,028 9,157,444

HP.6 Providers of preventive care

3,110,000 59,984 78,350 80,925,068 84,173,402

Government health administration agencies

47,016,181 0 0 0 122,807

11,338 38,661,545 0 85,811,871

HP.8.3 Community health workers (or village health workers, community health aides, etc.)

660,000 2,185,880 2,845,880

HP.9 Other countries of the world

9,525,544 9,525,544

HP.nec Unspecified healthcare providers (n.e.c.)

50,000 106,008 156,008

All HP 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

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 Government sources


Households

Household

38 | P a g e

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

Reported currency: US Dollar Healthc

are

provide

rs

HP.1.1

HP.2.2

HP.3.4.9

HP.4.1 HP.4.2

HP.4.9

HP.5.1

HP.5.2 HP.6 HP.7.1

HP.8.2 HP.8.3

HP.8.9

HP.9 HP.nec

All HP

Heal

thca

re

func

tions

Gen

eral

hos

pita

ls

Men

tal h

ealth

and

su

bsta

nce

abus

e fa

cilit

ies

All

Oth

er a

mbu

lato

ry

cent

ers Pr

ovid

ers o

f pat

ient

tra

nspo

rtatio

n an

d em

erge

ncy

resc

ue

Med

ical

and

dia

gnos

tic

labo

rato

ries

Oth

er p

rovi

ders

of

anci

llary

serv

ices

Phar

mac

ies

Ret

ail s

elle

rs a

nd o

ther

su

pplie

rs o

f dur

able

m

edic

al g

oods

and

m

edic

al a

pplia

nces

Pr

ovid

ers o

f pre

vent

ive

care

Gov

ernm

ent h

ealth

ad

min

istra

tion

agen

cies

All

othe

r ind

ustri

es a

s se

cond

ary

prov

ider

s of

heal

thca

re

Com

mun

ity h

ealth

w

orke

rs (o

r vill

age

heal

th w

orke

rs,

com

mun

ity h

ealth

aid

es,

etc.

) O

ther

indu

strie

s n.e

.c.

Oth

er c

ount

ries o

f the

w

orld

Uns

peci

fied

heal

thca

re

prov

ider

s (n.

e.c.

)

HC.1.1.1


276,974,708.

6

607,507.6

0.0 277,582,216.2

HC.1.1.2

Specialized inpatient curative care

32,107,356.9

3,320,000.0

0.0 0.0 35,427,356.9

HC.1.2.2

Specialized day curative care

12,390,087.4

0.0 0.0 12,390,087.4

HC.1.3.1

General outpatient curative care

10,530,712.3

307,438,788.1

0.0 495,804.6

1,834,720.0

320,388,973.0

39 | P a g e

HC.1.3.3

Specialized outpatient curative care

563,186.

4

5,115,073.0

0.0 5,678,259.4

HC.2.1

Inpatient rehabilitative care

3,619,576.0

0.0 0.0 3,619,576.0

HC.2.2

Day rehabilitative care

0.0 0.0 230,543.0

0.0 230,543.0

HC.2.3

Outpatient rehabilitative care

110,000.

0

235,353.0

0.0 345,353.0

HC.1.1+HC.2.1

Inpatient curative and rehabilitative care

312,701,641.

4

3,320,000.0

607,507.6

0.0 316,629,149.0

HC.1.2+HC.2.2

Day curative and rehabilitative care

12,390,087.4

0.0 230,543.0

0.0 12,620,630.4

HC.1.3+HC.2.3

Outpatient curative and

11,203,898.7

312,789,214.2

0.0 495,804.6

1,834,720.0

326,412,585.5

40 | P a g e

rehabilitative care

HC.4.1

Laboratory services

0.0 28,838.0

788,364.4

550,000.0

0.0 1,367,202.4

HC.4.3

Patient transportation

104,140,023.

9

145,474,729.3

30,000.0

0.0 10,000.0

249,654,753.2

HC.4.nec

Unspecified ancillary services (n.e.c.)

34,386.0

0.0 152,468.4

0.0 186,854.4

HC.5.1.1

Prescribed medicines

342,667,184.

9

0.0 478,780,427.

4

0.0 821,447,612.3

HC.5.2.1

Glasses and other vision products

0.0 0.0 6,331,785.9

0.0 6,331,785.9

HC.5.2.2

Hearing aids

0.0 0.0 1,948,241.8

0.0 1,948,241.8

HC.5.2.3

Other orthopedic appliances and prosthetics (excluding

0.0 0.0 646,873.0

0.0 646,873.0

41 | P a g e

glasses and hearing aids)

HC.6.1.1.nec

Other and unspecified addictive substances IEC programs (n.e.c.)

0.0 0.0 201,972.6

0.0 201,972.6

HC.6.1.2

Nutrition IEC programs

0.0 413,655.7

5,525,800.3

0.0 1,893,534.0

7,832,989.9

HC.6.1.3

Safe sex IEC programs

0.0 0.0 78,348.6

0.0 78,348.6

HC.6.1.nec

Other and unspecified IEC programs (n.e.c.)

0.0 0.0 3,127,968.5

0.0 101,630.

5

81,919.0

3,311,518.0

HC.6.2

Immunization programs

0.0 158,950.5

57,218,757.4

0.0 57,377,707.9

42 | P a g e

HC.6.4

Healthy condition monitoring programs

79,409.2

0.0 0.0 79,409.2

HC.6.5.1


0.0 0.0 5,805.0

5,805.0

HC.6.6

Preparing for disaster and emergency response programs

0.0 131,006.3

5,525,800.3

5,521.0

5,662,327.5

HC.6.7

Food distribution for preventing malnutrition

0.0 29,589,769.0

315,573.0

0.0 100,576.3

2,143,366.0

32,149,284.3

HC.6.8

Preventive care of HIV,TB, malaria, and vaccine-preventa

0.0 3,758,932.2

2,723,209.9

0.0 6,482,142.1

43 | P a g e

ble disease

HC.6.9

Prevention and public health services

0.0 4,492,773.8

9,455,971.3

10,141.0

2,239,498.7

3,551,327.9

22,287.8

21,714,636.1

HC.6.nec

Unspecified preventive care (n.e.c.)

0.0 0.0 0.0 965.5

965.5

HC.7.1.1


0.0 0.0 538,382.0

538,382.0

HC.7.1.2

Monitoring & evaluation (M&E)

0.0 0.0 434,623.0

434,623.0

HC.7.1.3

Procurement & supply management

0.0 0.0 806,042.0

806,042.0

HC.7.1.4

Leadership, management, and administrative

0.0 0.0 41,150,240.

9

41,150,240.9

44 | P a g e

HC.7.1.5

Administration of TB program

0.0 0.0 363,476.8

363,476.8

HC.7.1.6

Administration of malaria program

0.0 0.0 322,165.2

322,165.2

HC.7.1.7

Administration of CH program

0.0 0.0 748,775.8

748,775.8

HC.7.1.8

Administration of RH program

0.0 0.0 2,904,269.3

2,904,269.3

HC.7.1.9

Administration of HIV/AIDS program

0.0 0.0 1,948.9

1,948.9

HC.7.1.nec

Other governance and health system administration (n.e.c.)

0.0 0.0 38,520,480.

0

38,520,480.0

HC.9

Other healthcare services

0.0 158,950.5

0.0 51,800.9

210,751.4

45 | P a g e

not classified elsewhere (n.e.c.)

All HC 783,216,631.

5

3,320,000.0

497,604,327.0

30,000.0

788,364.4

702,468.4

478,780,427.

4

9,157,443.7

84,173,401.9

85,811,871.

0

2,845,879.6

9,525,543.9

156,007.7

1,958,143,950.

0

Memorandum

items

0.0 0.0

HCR.2.3

Community mobilization

0.0 0.0 189,276.0

189,276.0

HCR.2.4

Education and training of health personnel

38,836.1

496,621.4

88,232.5

3,149,261.9

931,028.

5

693,673.

0

6,027,931.6

HCR.2.5

Other food, hygiene, and drinking water control

0.0 0.0 570,808.6

664.7

571,473.3

HCR.2.6

Other research and development in health

0.0 0.0 199,685.

6

277,501.

0

477,186.6

46 | P a g e

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

Reported currency: US Dollar Financing

agents

FA.1.1.1 FA.1.1.5 FA.1.1.6 FA.1.1.7 FA.1.1.8

FA.4 FA.5 FA.7 All FA

Financing schemes

Min

istry

of

Pub

lic

Hea

lth

Min

istry

of

Def

ense

Min

istry

of

Inte

rior

Aff

airs

Min

istry

of

Hig

her

Educ

atio

n

Min

istry

of

Ed

ucat

ion

Non

prof

it in

stitu

tions

se

rvin

g ho

useh

old

s (N

PISH

)

Hou

seho

ld s

Oth

er

coun

tries

of

the

wor

ld

HF.1.1.1.1 Ministry of Public Health

203,331,791

2,475,445 358,338 206,165,574

HF.1.1.1.2 Ministry of Defense

21,597,442

21,597,442

HF.1.1.1.3 Ministry of Interior Affairs

9,348,241

9,348,241

HF.1.1.1.4 Ministry of Higher Education

7,674,712

7,674,712

HF.1.1.1.5 Ministry of Education

208,539 208,539

HF.2.2.1 NPISH financing schemes (excluding HF.2.2.2)

3,725,504

3,725,504

HF.2.2.2 Resident foreign agencies’ schemes

67,193 2,055,261

276,761,381

278,883,835

HF.3.1 Out-of-pocket, excluding cost sharing

1,430,540,103

1,430,540,103

All HF 203,398,984

24,072,887

9,348,241

7,674,712

208,539 6,139,102

1,430,540,103

276,761,381

1,958,143,950

47 | P a g e

Table A.6: Financing Sources, by Diseases, FS X DIS

Reported currency: US Dollar Non-disease-specific expenditures reported separately

Revenues of healthcare financing schemes FS.1.1.1 FS.2 FS.6.3 FS.7.1.4 FS.8.1 All FS

Classification of

diseases /

conditions

Cen

tral

gove

rnm

ent

reve

nue

Tran

sfer

s di

strib

uted

by

gove

rnm

ent

from

fore

ign

orig

in

Oth

er re

venu

es

from

NPI

SH

n.e.

c.

Dire

ct fo

reig

n fin

anci

al

trans

fer

Hou

seho

lds’

ou

t-of-

pock

et

DIS.1.1.1.1 HIV/AIDS 1,480,000

78,349

2,467,044

4,025,392

DIS.1.2.3 TB treatment (general) 313,148

199,353

806

18,158,951

2,696,541

21,368,799

DIS.1.3 Malaria 86,199

1,701,682

4,647

9,534,286

5,640,387

16,967,201

DIS.1.7 Vaccine-preventable diseases 770,698

770,698

DIS.2.1 Maternal conditions 697,618

5,292,442

57,721

8,545,440

44,239,469

58,832,690

DIS.2.2 Perinatal conditions 1,215,935

8,843,110

98,905

4,123,682

75,804,044

90,085,675

DIS.2.3 Contraceptive management (family planning) 1,132,664

8,581,442

96,024

5,025,149

73,596,160

88,431,439

DIS.2.4 SBA 1,303,493

9,491,609

106,160

4,843,153

81,364,643

97,109,058

DIS.7.1 ARI 2,690,216

26,813,457

281,491

7,083,140

246,926,222

283,794,526

DIS.7.2 Diarrheal disease 2,296,284

8,036,760

70,606

3,320,179

83,217,639

96,941,469

DIS.7.3 Malnutrition (nutritional deficiencies) 819,049

4,076,961

39,224

52,163,493

39,936,930

97,035,658

DIS.7.4 Anemia 366,002

1,603,935

18,138

448,290

13,901,497

16,337,862

48 | P a g e

DIS.7.5 Child immunization 2,127,764

7,475,741

72,551

50,310,033

59,986,089

DIS.7.6 Other 31,839,215

58,143,182

2,800,883

74,825,357

763,216,572

930,825,209

DIS.8 Governance, management, and administration 44,466,270

4,730,000

5,948,349

55,144,619

DIS.9 All diseases of IPD & OPD 7,565,134

795,841

25,440,191

33,801,166

DIS.10 Health promotion lifesaving through RMNCH 47,839

47,839

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

210,000

600,000

5,828,561

6,638,561

All DIS 97,128,992

147,865,516

3,725,504

278,883,835

1,430,540,103

1,958,143,950

49 | P a g e

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

Healthcare

providers

HP.1 HP.1.1 HP.1.2 HP.1.3 HP.3 HP.3.4.9 HP.4 HP.6 HP.7 HP.7.4 HP.8 HP.nec All HP

Capital Account

Hos

pita

ls

Gen

eral

ho

spita

ls

Men

tal

heal

th

hosp

itals

Sp

ecia

lized

ho

spita

ls

(oth

er th

an

men

tal h

ealth

ho

spita

ls)

Prov

ider

s of

ambu

lato

ry

heal

thca

re

All

othe

r am

bula

tory

ce

nter

s

Prov

ider

s of

anci

llary

se

rvic

es

Prov

ider

s of

prev

entiv

e ca

re

Prov

ider

s of

heal

thca

re

syst

em

adm

inis

tratio

n an

d fin

anci

ng

Gov

erna

nce,

te

chni

cal

assi

stan

t ad

min

istra

tiv e

Res

t of

econ

omy

Uns

peci

fied

heal

thca

re

prov

ider

s (n

.e.c

.)

HK.1.1.1.1 Residential and non-residential buildings

502,961

3,063,061

3,566,022

HK.1.1.1.2 Other structures 1,227,916 532,662 21,706 2,303,467 3,684,573 00,000 500,253 1,067,641 4,137,584 13,675,804 HK.1.1.2.1 Medical

equipment 2,418,034

4,322,864

24,505 13,587

234,583

7,013,572

HK.1.1.2.2 Transport equipment

2,197,015

26,700

7,197

2,230,912

HK.1.1.2.3 ICT equipment 264,076 11,189 9,925 92,915 11,000 1,999 1,999 593,103 HK.1.1.2.4 Machinery and

equipment n.e.c.

380,196 1,470,839

14,063

1,468,979

138,219

154,773

1,067,537

49,143

4,743,749

HK.1.1.3.1 Computer software and databases

140,760

140,760

HK.1.nec Unspecified gross capital formation (n.e.c.)

377,183 796,865

10,522

301,931

27,915

216,201

34,842

29,653

1,795,113

HK.2.2 Other non-produced, non-financial assets

43,616

43,616

HK.nec Unspecified gross fixed capital formation (n.e.c.)

41,335

12,466

53,801

All HK 4,667,405 532,662

21,706

2,314,656

13,210,754

3,287,646

24,505

2,577,665

1,518,524

370,975

5,249,159

80,795

33,856,452

50 | P a g e

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 1,430,540,103 71.81% MoPH as government revenue expenditure 99,581,150 5.00% USAID 80,671,944 4.05% UNICEF 49,706,104 2.50% World Bank 41,060,000 2.06% WHO 35,539,545 1.78% MoD 29,243,500 1.47% MSF 25,954,110 1.30% EU 25,534,092 1.28% JICA 24,464,213 1.23% WFP 22,462,584 1.13% Multiple donors 21,359,934 1.07% ISAF 16,367,422 0.82% CIDA 15,040,546 0.76% GAVIHSS 10,145,662 0.51% ICRC 10,074,229 0.51% UNFPA 9,698,664 0.49% MoI 9,348,241 0.47% Emergency 9,276,001 0.47% MoHE 7,674,713 0.39% AKDN 6,439,470 0.32% TIKA 4,423,473 0.22% ARCS 4,296,977 0.22% IFRC 2,460,168 0.12% Italian cooperation 340,788 0.02% MoE 296,772 0.01%

Total Health Expenditure 1,992,000,405 100%

51 | P a g e

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.

52 | P a g e

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.

Afghanistan third round of National Health Accounts,

including disease accounts, covers the estimates of

health spending for the year 2014.

afghanistan national health accounts with disease … · summary of findings in comparison with...

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