Following the collapse of the Taliban in 2001, Afghanistan was left with a dysfunctional health system, dismal health outcomes due to destruction of infrastructure, and loss of workforce. In 2002, the maternal mortality ratio was 1600 per 100,000 live births, the highest ever recorded. The infant and child mortality rates were 165 and 257 per 1000 live births, respectively.1 Additionally, less than 10% of the population lived within a one hour walking distance to a facility.1 Over just a few years, Afghanistan successfully implemented a series of reforms to improve PHC service delivery - and specifically geographic and financial access – resulting in rapid improvements in health outcomes.

What are user fees and what does it mean to remove them?

User fees first became common in the 1980s as a strategy to increase revenue an improve efficient use of services. However, they were found to prevent access to care, particularly among the poor. As a result, many countries have begun removing user fees int he last few decades as a mechanism to promote financial access to care.

How access was integrated into health system reforms:

In an effort to rebuild following the conflict, the Ministry of Public Health (MoPH) implemented a health financing pilot program to understand the effects of different methods of financial access strategies and select one that was the most suitable to their context.2 The three types of interventions implemented were standard user fees with fee waivers for specific segments of the population, community health funds, and free services. The pilot was initiated in 2005, an in 2008 the MoPH instituted a national ban on user fees for primary care services.

Concurrently, the MoPH worked with a number of other organizations to address the fragmented nature of health services in Afghanistan. In 2002, 80% of the services were delivered by international organizations or national NGOs with a focus on vertical programs, leading to significant gaps in primary care services and inequitable distribution.1 In response, the MoPH designed a Basic Package of Health Services (BPHS) intended to encompass all basic PHC needs. The components of the BPHS were maternal and newborn health, child health and immunization, public nutrition, communicable diseases, and regular supply of essential drugs, with mental health and disability services available at select BPHS facilities.1 

Because NGOs had previously provided many of the services identified in the BPHS, the MoPH aimed to increase efficiency and minimize the need for new infrastructure by contracting with NGOs in a competitive bidding process with 1-3 year contracts and payment contingent upon NGOs meeting pre-determined goals. Additionally, each type of service delivered through the BPHS was mapped to a type of health facility at which it could be appropriately provided, and monitoring and evaluation strategies were designed concurrently.1 Since 2005, there have been a number of additional changes to the BPHS, including the prioritization of mental health and disability services at all BPHS facilities, the development of an essential package of hospital services, and expanded services at each level of health facilities. The BPHS demonstrates a commitment to increased access through the physical availability of facilities as well as integrated and standardized services across locations.

Outcomes & impact

There has been an increase in utilization of services – particularly of curative care - following the removal of user fees and implementation of the BPHS. Overall, total annual visits increased from two million to 44.8 million and there was a 4000% increase in skilled birth attendance over seven years.12 The BPHS has expanded considerably, with a 70% increase in the number of BPHS facilities between 2004 and 2011. These facilities have also seen uptake in information systems and use of data for improvement, with 90% of facilities reporting data in 2011, and 75% of health posts providing routine statistics.1

Health indicators in Afghanistan have improved substantially since 2002. The maternal mortality ratio decreased from 1600 to 327 per 100,000 live births in 2010, and infant and under 5 mortality decreased from 165 to 77 and 257 to 97 per 1000 live births, respectively. Afghanistan’s next steps in service delivery are two-fold: ensuring the sustainability of services as donor support decreases, and securing care for the remaining hard-to-reach populations through community-based outreach and care.1


  1. Newbrander W, Ickx P, Feroz F, Stanekzai H. Afghanistan’s basic package of health services: its development and effects on rebuilding the health system. Glob Public Health. 2014;9 Suppl 1:S6-28.
  2. Steinhardt LC, Aman I, Pakzad I, Kumar B, Singh LP, Peters DH. Removing user fees for basic health services: a pilot study and national roll-out in Afghanistan. Health Policy Plan. 2011 Nov;26 Suppl 2:ii92-103.