The need to sustain funding for Afghanistan health system to prevent excess morbidity and mortality

BACKGROUND: The Afghanistan Reconstruction Trust Fund, managed by the World Bank through a contracted-out instrument called Sehatmandi, financed health service delivery in Afghanistan, with substantial achievements in infant, child and maternal health. After the collapse of the Afghan Government on 15 August 2021, the health system has been on the brink of collapse. AIMS: We assessed the use of basic health services and estimated excess mortality resulting from the interruption to healthcare funding. METHODS: We conducted a cross-sectional study that compared health services utilization from June to September for 3 consecutive years, 2019, 2020 and 2021, using 11 output indicators reported by the health management and information system. We used the Lives Saved Tool, a linear mathematical model with input data from the Afghanistan Demographic Health Survey 2015, to calculate the additional maternal, neonatal and child mortality at 25%, 50%, 75% and 95% reduction in health coverage. RESULTS: During August and September 2021, after the announced ban on financing, health service utilization decreased to a range of 7-59%. Family planning, major surgeries and postnatal care showed the greatest decreases. Uptake of child immunization showed one-third decrease. Sehatmandi provides around 75% of primary and secondary health services: pausing funds to this programme will result in additional 2862 maternal deaths, 15 741 neonatal deaths, 30 519 child deaths, and 4057 stillbirths. CONCLUSION: Sustaining the current level of health services delivery is crucial to avoid excess, preventable morbidity and mortality in Afghanistan. Contexte : Le Fonds d'affectation spéciale pour la reconstruction de l'Afghanistan, géré par la Banque mondiale au moyen d'un programme sous-traité appelé Sehatmandi, a financé la prestation de services de santé en Afghanistan, ce qui a permis d'obtenir des résultats substantiels en matière de santé du nourrisson, de l'enfant et de la mère. Après la chute du Gouvernement afghan le 15 août 2021, le système de santé était sur le point de s'effondrer. Objectifs : Nous avons évalué le recours aux services de santé de base et estimé la surmortalité résultant de l'interruption du financement des soins de santé. Méthodes : Nous avons mené une étude transversale qui a permis de comparer l'utilisation des services de santé entre juin et septembre pendant trois années consécutives, de 2019 à 2021, à l'aide de 11 indicateurs de résultats rapportés par le système de gestion et d'information sanitaires. Nous avons utilisé l'outil des vies sauvées, un modèle mathématique linéaire basé sur les données fournies par l'enquête démographique et sanitaire d'Afghanistan menée en 2015, afin de calculer la mortalité supplémentaire de la mère, de l'enfant et du nourrisson pour une réduction de 25 %, 50 %, 75 % et 95 % de la couverture sanitaire. Résultats : En août et septembre 2021, après l'annonce de l'interdiction des financements, l'utilisation des services de santé a chuté pour atteindre une fourchette de 7 à 59 %. La planification familiale, les interventions chirurgicales majeures et les soins postnatals ont enregistré les baisses les plus importantes. L'utilisation des services de vaccination des enfants a diminué d'un tiers. Le programme Sehatmandi fournit près de 75 % des services de santé primaires et secondaires : l'interruption des fonds alloués à ce programme entraînera 2862 décès maternels, 15 741 décès néonatals, 30 519 décès d'enfants et 4057 mortinaissances supplémentaires. Conclusion : Il est essentiel de maintenir le niveau actuel de prestation des services de santé afin d'éviter une morbidité et une mortalité excessives qui peuvent être prévenues en Afghanistan

A study protocol for integrating outpatient services at the primary health care level as part of the universal health coverage benefit package within the national health insurance program of Pakistan through private health facilities

Introduction and aimPakistan has a mixed-health system where up to 60% of health expenditures are out of pocket. Almost 80% of primary healthcare (PHC) facilities are in the private sector, which is deeply embedded within the country’s health system and may account for the unaffordability of healthcare. Since 2016, the existing national health insurance program or Sehat Sahulat Program (SSP), has provided invaluable coverage and financial protection to the millions of low-income families living in Pakistan by providing inpatient services at secondary and tertiary levels. However, a key gap is the non-inclusion of outpatient services at the PHC in the insurance scheme. This study aims to engage a private provider network of general practitioners in select union councils of Islamabad Capital Authority (ICT) of Pakistan to improve access, uptake, and satisfaction and reduce out-of-pocket expenditure on quality outpatient services at the PHC level, including family planning and reproductive health services.Methods and analysisA 24-month research study is proposed with a 12-month intervention period using a mixed method, two-arm, prospective, quasi-experimental controlled before and after design with a sample of 863 beneficiary families from each study arm, i.e., intervention and control groups (N = 1726) will be selected through randomization at the selected beneficiary family/household level from four peri-urban Union Councils of ICT where no public sector PHC-level facility exists. All ethical considerations will be assured, along with quality assurance strategies. Quantitative pre/post surveys and third-party monitoring are proposed to measure the intervention outcomes. Qualitative inquiry with beneficiaries, general practitioners and policymakers will assess their knowledge and practices.Conclusion and knowledge contributionPHC should be the first point of contact for accessing health services and appears to serve as a programmatic engine for universal health coverage (UHC). The research aims to study a service delivery model which harnesses the private sector to deliver an essential package of health services as outpatient services under SSP, ultimately facilitating UHC. Findings will provide a blueprint referral system to reduce unnecessary hospital admissions and improve timely access to healthcare. A robust PHC system can improve population health, lower healthcare expenditure, strengthen the healthcare system, and ultimately make UHC a reality

Benefit-risk analysis of maintaining essential Reproductive, Maternal, Newborn, and Child Health (RMNCH) services against risk of COVID-19 infection.

With the COVID-19 pandemic spreading across the world, its disruptive effect on the provision and utilization of non- COVID related health services have become well-documented. As countries developed mitigation strategies to help continue the delivery of essential health services through the pandemic, they needed to carefully weigh the benefits and risks of pursuing these strategies. In an attempt to assist countries in their mitigation efforts, a Benefit-Risk model was designed to provide guidance on how to compare the health benefits of sustained essential reproductive, maternal, newborn and child (RMNCH) services against the risk of SARS-CoV-2 infections incurred by the countries' populations when accessing these services. This article describes how two existing models were combined to create this model, the field-testing process carried out from November 2020 through March 2021 in six countries and the findings. The overall Benefit-Risk Ratio in the 6 countries analyzed was found to be between 13.7 and 79.2, which means that for every 13.7 to 79.2 lives gained due to increased RMNCH service coverage, there was one loss of a life related to COVID-19. In all cases and for all services, the benefit of maintaining essential health services far exceeded the risks associated with additional COVID-19 infections and deaths. This modelling process illustrated how essential health services can continue to operate during a pandemic and how mitigation measures can reduce COVID-19 infections and restore or increase coverage of essential health services. Overall, this Benefit-Risk analysis underscored the importance and value of maintaining coverage of essential health services even during public health emergencies, including the recent COVID-19 pandemic