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By the time the Taliban were overthrown in November 2001, Afghanistan had endured over two decades of conflict. The instability of war combined with existing poor infrastructure, limited access to safe water, sanitation and health services, and poverty, to place Afghanistan among the least developed nations in the world.

Currently, different parts of Afghanistan are at different stages of insecurity—some parts are post-conflict, others are still in-conflict, and others experience periodic conflict. The influx of development funds and private business, as well as growing capacity within Afghanistan, have resulted in a growing pool of actors holding conflicting interests and rapidly changing formal and informal institutions. It is unclear how the context is affecting health service use.

FHS Phase 1

Since 2003, the Johns Hopkins Bloomberg School of Public Health (JHSPH) and the Indian Institute of Health Management Research (IIHMR) have been working with the Ministry of Public Health (MoPH) in Afghanistan to implement a ‘Balanced Scorecard’ for monitoring the effectiveness of health services across the country. The long-running project, funded directly by the MoPH, offered FHS an important opportunity to feed into ongoing processes in the country, supporting work specifically around maternal health.

Maternal health is acknowledged to be pivotal in the maintenance of household health and well-being. Maternal health indicators in Afghanistan are among the worst in the developing world. Strong political will and acknowledgment of maternal health as a health and development priority has led to improvements in both the quantity and quality of maternal health services. However, despite the known risks of child-bearing and the increase in supply of services, maternal health care service use remains very low.

The main effort for FHS in the first phase was to understand how vulnerabilities at multiple levels and rapidly changing contextual factors influence utilization of maternal health services by women in Afghanistan, and to determine the kinds of interventions which may increase appropriate utilization of maternal health care services.

FHS Phase 2 focus

In Afghanistan, the government has made significant improvements in performance of the basic health package of services as illustrated by the results of the balanced scorecard. However, there is inadequate documentation of the institutionalization and effectiveness of these systems, and of communication of results from health facility and community surveys to the peripheral health units and the communities. The results of the scorecard are mainly disseminated at the national and provincial levels and additional efforts must be made to cascade the information to the point of service delivery to enable problem solving strategies for service improvement.

To improve feedback at a community level, FHS's work in Phase 2 is expected to focus on the development and piloting of a community scorecards (CSCs), which have shown promising potential in generating community commitment and empowerment to ensure quality and health service delivery in other settings.

FHS partners in Afghanistan

Recent FHS Afghanistan Publications


The Afghanistan experience of nearly 15 years of contracting for health services has demonstrated both how results-based financing (RBF) can serve to increase utilisation of health services and the equity in use, as well as the limitations and failings of RBF approaches to work consistently.

Future Health Systems (FHS) findings, generated through robust experimental and quasi-experimental studies in a rapidly changing context, suggests that attention to scheme design (especially to address demand side concerns, supply side capabilities, and the size and mechanisms of payments) and implementation (timeliness and communication about payments) are critical.

Bennett S, Mahmood SS, Edward A, Tetui M and Ekirapa-Kiracho E (2017) Strengthening scaling up through learning from implementation: comparing experiences from Afghanistan, Bangladesh and Uganda, Health Research Policy and Systems, 15(Suppl 2):108, DOI: 10.1186/s12961-017-0270-0

Many effective innovations and interventions are never effectively scaled up. Implementation research (IR) has the promise of supporting scale-up through enabling rapid learning about the intervention and its fit with the context in which it is implemented. We integrate conceptual frameworks addressing different dimensions of scaling up (specifically, the attributes of the service or innovation being scaled, the actors involved, the context, and the scale-up strategy) and questions commonly addressed by IR (concerning acceptability, appropriateness, adoption, feasibility, fidelity to original design, implementation costs, coverage and sustainability) to explore how IR can support scale-up.

FHS Key Message Brief 3: Unlocking community capability: key to more responsive, resilient and equitable health systems

In Future Health Systems, we focused on communities as active service delivery participants across a wide variety of contexts. In this brief, we reflect on the process of unlocking community capabilities, the key actors involved, and the productive tensions within community partnerships forged to build more responsive, resilient and equitable health systems.

Engineer C, Dale E, Agarwal A, Agarwal A, Alonge O, Edward A, Gupta S, Schuh H, Burnham G, Peters DH (2016) Effectiveness of a pay for performance intervention to improve maternal and child health services in Afghanistan: A cluster-randomized trial, International Journal of Epidemiology, doi: 10.1093/ije/dyv362

A cluster randomized trial of a pay-for-performance (P4P) scheme was implemented in Afghanistan to test whether P4P could improve maternal and child (MCH) services. The authors found that the intervention had minimal effect, possibly due to difficulties communicating with health workers and inattention to demand-side factors. P4P interventions need to consider management and community demand issues.


Tappis H, Koblinsky M, Doocy S, Warren N, Peters DH (2016) Bypassing primary care facilities for childbirth: findings from a multilevel analysis of skilled birth attendance determinants in Afghanistan, Journal of Midwifery and Women’s Health, Volume 61, Issue 2, pages 185–195, DOI: 10.1111/jmwh.12359

The objective of this study was to assess the association between health facility characteristics and other individual/household factors with a woman's likelihood of skilled birth attendance in north-central Afghanistan. The study finds that assumptions that women who give birth with a skilled attendant do so at the closest health facility may mask the importance of supply-side determinants of skilled birth attendance. More research based on actual utilization patterns, not assumed catchment areas, is needed to truly understand the factors influencing care-seeking decisions in both emergency and nonemergency situations and to adapt strategies to reduce preventable mortality and morbidity in Afghanistan.