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A number of development partners, including the World Bank, have been actively supporting the health sector in Afghanistan since 2003-04 (1382 AC). Collectively, they invested more than $820 million between 2003 (1382 AC) and 2008-09 (1387 AC) and played key roles in supporting the government in reshaping the country's health sector. This support continues, with all partners starting new projects aimed at further strengthening the sector and building on the successes that have been achieved. The book is organized as follows. Chapters one-four tell a coherent story about the achievements of the sector between 2002 and 2008 (1381-87AC), the financial resources used to achieve the results, and the contribution the private sector has made to the achievements. Chapters five-eight) look forward. They identify the challenges the sector is facing in meeting human resource needs, expanding the coverage of the basic package of health services (BPHS), and increasing the institutional capacity of the Ministry of Public Health (MoPH). Chapter eight summarizes the lessons learned and provides options for moving forward.

The Ministry of Public Health-(MOPH) in Afghanistan has developed a balanced scorecard (BSC) to regularly monitor the progress of its strategy to deliver a basic package of health services. Although frequently used in other health-cafe settings, this represents the first time that the BSC has been employed in a developing country, The BSC was designed via a collaborative process focusing on translating the vision and mission of the MOPH into 29 core indicators and benchmarks representing six different domains of health services, together with two composite measures of performance. In the absence of a routine health information system, the 2004 BSC for Afghanistan was derived from a stratified random sample of 617 health facilities, 5719 observations of patient-provider interactions, and interviews with 5597 patients, 1553 health workers, and 13 843 households. Nationally, health services ware found to be reaching more of the poor than the less-poor population, and providing for more women than men, both key concerns of the government. However, serious deficiencies were found in five domains, and particularly in counselling patients, providing delivery care during childbirth, monitoring tuberculosis treatment, placing staff and equipment, and establishing functional village health councils. The BSC also identified wide variations in performance across provinces, no province performed better than the others across all domains. The innovative adaptation of the BSC in Afghanistan has provided a useful tool to summarize the multidimensional nature of health-services performance, and is enabling managers to benchmark performance and identify strengths and weaknesses in the Afghan-context. Adapted from the source document.

This report evaluates the outcomes of World Bank Group support to Afghanistan from 2002-11. Despite extremely difficult security conditions, which deteriorated markedly after 2006, the World Bank Group has commendably established and sustained a large program of support to the country. The key messages of the evaluation are:•While World Bank Group strategy has been highly relevant to Afghanistan’s situation,beginning in 2006 the strategies could have gone further in adapting ongoingprograms to evolving opportunities and needs, and in programming activities sufficientto achieve the objectives of the pillars in those strategies.•Overall, Bank Group assistance has achieved substantial progress toward most ofits major objectives, although risks to development outcomes remain high. Impressive results have been achieved in public financial management, public health,telecommunications, and community development; substantial outputs have alsobeen achieved in primary education, rural roads, irrigation, and microfinance—allstarted during the initial phase. Bank assistance has been critical in developingthe mining sector as a potential engine of growth. However, progress has beenlimited in civil service reform, agriculture, urban development, and private sectordevelopment.•The Bank Group’s direct financial assistance has been augmented effectively byanalytic and advisory activities and donor coordination through the AfghanistanReconstruction Trust Fund. Knowledge services have been an important part ofBank Group support and have demonstrated the value of strategic analytical work,even in areas where the Bank Group may opt out of direct project financing.•With the expected reduction of the international presence in 2014, sustainabilityof development gains remains a major risk because of capacity constraints andinadequate human resources planning on the civilian side.To enhance program effectiveness, the evaluation recommends that the Bank Group help the government develop a comprehensive, long-term human resources strategy for the civilian sectors; focus on strategic analytical work in sectors that are high priorities for the government; assist in the development of local government institutions and, in the interim, support the development of a viable system for servicedelivery at subnational levels; assist in transforming the National Solidarity Program into a more sustainable financial and institutional model to consolidate its gains; help strengthen the regulatory environment for private sector investment; and scale up IFC and MIGA support to the private sector.Chapter AbstractsChapter 1This chapter examines the country context, including continuing conflict and insecurity, poverty, and the role of development partners and non-state actors (civil society and humanitarian organizations) in Afghanistan. It examines coming transitions in security arrangements, including political and economic transitions. It outlines the evaluation methods used, as well as limitations. Chapter 2This chapter deals with the World Bank Group strategy and program, the Bank Group’s operational program, portfolio performance, analytic and advisory activities review, the Afghanistan Reconstruction Fund, and the new Interim Strategy Note, as well as previous Transitional Support Strategies and ISNs.Chapter 3This chapter examines the building of state capacity and state accountability to its citizens, specifically issues such as results and shortcomings in public financial management, public sector governance, and health and education. The World Bank Group contribution is highlighted. Risks to development outcomes are discussed. Chapter 4This chapter examines the issue of promoting growth in the rural economy and improving rural livelihoods, including sectors such as rural roads, agriculture and water. The National Solidarity Program and the Bank Group’s contribution to it are discussed. Risks to development outcomes arenoted.Chapter 5This chapter concerns support for the formal private sector, examining the overall investment climate and financial sector. It looks at possibilities for growth in the mining and hydrocarbons sector, information and communications technology, and power sectors. Urban development is also examined. The World Bank Group contribution is highlighted.Chapter 6This chapter provides an overall assessment (relevance, efficacy) of the Bank Group’s program in Afghanistan, outlining the internal and external drivers of success (knowledge services, staff capacity, customization of program design to country context, alignment of donor objectives, etc) and weakness. Chapter 7This chapter outlines the lessons for fragile and conflict-affected situations drawing on the specifics of the Afghanistan evaluation case. Recommendations are offered in areas such as labor markets, human resources, strategic-level analytical work vis-a-vis long-term development strategies, and strengthening of the regulatory environment for private sector investment.

Objectives The aim of this study was to examine the effects of simulation-based breast health education on Afghan women's awareness of breast cancer, including knowledge of its risk factors, signs, and symptoms, as well as to improve their breast self-examination skills. Study design This study was a pre-test, post-test, parallel-arm randomized controlled trial. Methods The study sample consisted of 46 Afghan women, with 23 participants assigned to each of the intervention and control groups using block randomization. This study was conducted at the Social Development and Aid Mobilization (SGDD-ASAM) in Ankara, Türkiye. The intervention group received simulation-based breast health training. Each session of breast health education was 180 min. The simulation used a one-to-one show-and-do technique, which took approximately 120 min. Data were collected using the Breast Cancer Awareness Measure and the Breast Self-Examination Skill Assessment Form. The data were analyzed with the IBM SPSS 26 program. Descriptive statistics were used to evaluate the study data, including mean, standard deviation, percentage, and frequency distribution. The Shapiro–Wilk normality test was applied for further analysis. The Chi-Square (X 2 ) Test was used to compare outcomes between groups. The significance level of p  < 0.05 was considered. Results After the simulation-based training, there was a significant increase in confidence, skills, and behavior awareness among participants in the intervention group compared to the control group ( p  < 0.001). While there was no change in the control group, awareness of breast cancer, knowledge, and skills in the intervention group were predominantly rated as sufficient. Conclusions The simulation-based breast health education intervention for Afghan refugee women was found to be a practical and innovative approach to raising breast cancer awareness and providing breast self-examination skills. This intervention may play a significant role in identifying at-risk individuals and raising their awareness. If sustained, this could potentially increase future screening participation and early detection, ultimately contributing to improved patient outcomes. It is recommended that policymakers and health professionals prioritize the integration of simulation-based health education into prevention and health promotion strategies targeting disadvantaged populations, such as refugees and migrants, to improve early diagnosis and advance health equity. Trial registration Clinical Trials Number is NCT06051331. Registration date is 22.11.2023.

Background This is the ninth paper in our series, “Community Health Workers at the Dawn of a New Era”. Community health workers (CHWs) are in an intermediary position between the health system and the community. While this position provides CHWs with a good platform to improve community health, a major challenge in large-scale CHW programmes is the need for CHWs to establish and maintain beneficial relationships with both sets of actors, who may have different expectations and needs. This paper focuses on the quality of CHW relationships with actors at the local level of the national health system and with communities. Methods The authors conducted a selective review of journal articles and the grey literature, including case study findings in the 2020 book Health for the People: National CHW Programs from Afghanistan to Zimbabwe. They also drew upon their experience working with CHW programmes. Results The space where CHWs form relationships with the health system and the community has various inherent strengths and tensions that can enable or constrain the quality of these relationships. Important elements are role clarity for all actors, working referral systems, and functioning supply chains. CHWs need good interpersonal communication skills, good community engagement skills, and the opportunity to participate in community-based organizations. Communities need to have a realistic understanding of the CHW programme, to be involved in a transparent process for selecting CHWs, and to have the opportunity to participate in the CHW programme. Support and interaction between CHWs and other health workers are essential, as is positive engagement with community members, groups, and leaders. Conclusion To be successful, large-scale CHW programmes need well-designed, effective support from the health system, productive interactions between CHWs and health system staff, and support and engagement of the community. This requires health sector leadership from national to local levels, support from local government, and partnerships with community organizations. Large-scale CHW programmes should be designed to enable local flexibility in adjusting to the local community context.

This study examines the effects of long-run civil wars on healthcare, which is an important component of human capital development and their causality nexus in Afghanistan using the MVAR (modified vector autoregressive) approach and the Granger non-causality model covering data period 2002Q3-2020Q4. The primary results support a significant long-run relationship between variables, while the results of the MVAR model indicate the per capita cost of war, per capita GDP, and age dependency ratio have significantly positive impacts on per capita health expenditures, whereas child mortality rate and crude death rate have negative impacts. The results of the Granger non-causality approach demonstrate that there is a statistically significant bidirectional causality nexus between per capita health expenditure, per capita cost of war, per capita GDP, child mortality rate, crude death rate, and age dependency ratio, while it also supports the existence of strong and significant interconnectivity and multidimensionality between per capita cost of war and per capita health expenditure, with a significantly strong feedback response from the control variables. Important policy implications sourced from the key findings are also discussed.

Introduction Community health workers (CHWs) played a vital role in providing diverse essential health services to their communities during the pandemic. Using CHWs perspective, this study investigates barriers to seeking and delivery of essential health services in the nine Afghan communities during the COVID-19 pandemic. Method In this cross-sectional study, 107 primary health care clinics from 9 provinces were selected, in which around 45% of the total country population reside. We used the validated questionnaire “Community Needs, Perceptions and Demand, Community Assessment Tool” which was contextualized by WHO headquarters and the WHO Afghanistan office. Data was exported into Excel, cleaned, and then exported into and analyzed using STATA version 17. Result Most CHWs were men (80.9%), from rural areas (87.2%), and volunteers (58.1%). About 66.3% reported that lack of information about available services was a main barrier. Other reported barriers were a lack of transportation to health facilities (47.2%), their home were too far from health facilities (40.9%), and a perceived lack of medicines at facilities (23.6%). More than half of CHWs reported that they received some training on how COVID-19 spreads (67.2%), COVID-19 vaccine (65.4%), and how to use a mask properly while working (56.3%), while 27.2% said that they had not enough mask available to use. Conclusion Our research demonstrated that most barriers and concerns related to using critical services during a pandemic may be addressed by providing information about available services, providing transportation to facilities, and providing masks to personnel and individuals. CHWs could play critical role in managing and responding to emergencies and pandemics if the government invest on their capacity and motivation. Revision of training curriculum for CHWs and their job description to include the emergency and pandemic management at community level, and providing them monetary incentives are highly recommended.

Background Maternal and newborn mortality is a public health concern in low- and middle-income countries (LMICs), including Afghanistan, where the evolving socio-political circumstances have added new complexities to healthcare service delivery. Birth outcomes for both pregnant women and their newborns are improved if women receive benefits of quality antenatal care (ANC). Objectives This study aimed to assess the contents of ANC services and identify predictors of utilization of services by pregnant women during ANC visits to health facilities in Afghanistan. Methods In this cross-sectional study, we used data from the Afghanistan Health Survey 2018 (AHS2018). We included a total of 6,627 ever-married women, aged 14–49 years, who had given birth in the past 2 years or were pregnant at the time of survey and had consulted a health worker for ANC services in a health facility. The outcome was defined as 1–4 services and 5–8 services that a pregnant woman received during an ANC visit. The services were (i) taking a pregnant woman’s blood pressure, (ii) weighing her, (iii) testing her blood, (iv) testing her urine, (v) providing advice on nutrition, (vi) advising about complicated pregnancy, (vii) advising about the availability of health services, and (viii) giving her at least one dose of Tetanus Toxoid (TT) vaccine. The binary outcome (1–4 services versus 5–8 services) was used in a multivariable logistic regression model. Results Of all 6,627 women, 31.4% (2,083) received 5–8 services during ANC visits. Only 1.3% (86) received all 8 services, with 98.7% (6,541) receiving between 1 and 7 services, and 71.6% (4,745) women had their blood pressure measured during ANC visits. The likelihood (adOR = Adjusted Odds Ratio) of receiving 5–8 services was higher in women who could read and write (adOR = 1.33: 1.15–1.54), in women whose husbands could read and write (adOR = 1.14: 1.00-1.28), in primipara women (adOR = 1.42: 1.02–1.98), in women who knew one danger sign (adOR = 5.38: 4.50–6.45), those who knew 2 danger signs (adOR = 8.51: 7.12–10.19) and those who knew ≥ 3 danger signs (adOR = 13.19: 10.67–16.29) of complicated pregnancy, and in women who had almost daily access to TV (adOR = 1.16: 1.01–1.33). However, the likelihood of receiving 5–8 services was lower in women who used private clinics (adOR = 0.64: 0.55–0.74) and who received services from nurses (adOR = 0.27 (0.08–0.88). Conclusion Our findings have the potential to influence the design and implementation of ANC services of health interventions to improve the delivery of services to pregnant women during ANC visits.