Lessons from the development process of the Afghanistan integrated package of essential health services

Abstract

In 2017, in the middle of the armed conflict with the Taliban, the Ministry of Public Health decided that the Afghan health system needed a well-defined priority package of health services taking into account the increasing burden of non-communicable diseases and injuries and benefiting from the latest evidence published by DCP3. This leads to a 2-year process involving data analysis, modelling and national consultations, which produce this Integrated Package of Essential health Services (IPEHS). The IPEHS was finalised just before the takeover by the Taliban and could not be implemented. The Afghanistan experience has highlighted the need to address not only the content of a more comprehensive benefit package, but also its implementation and financing. The IPEHS could be used as a basis to help professionals and the new authorities to define their priorities.

Full text

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SaeedzaiSA, etal. BMJ Glob Health 2023;8:e012508. doi:10.1136/bmjgh-2023-012508
Lessons from the development process
of the Afghanistan integrated package
of essential health services
Sayed Ataullah Saeedzai,1 Karl Blanchet ,2 Ala Alwan,3 Najibullah Sa,4
Ahmad Salehi,3 Neha S Singh ,3 Gerard Joseph Abou Jaoude ,5
Shaq Mirzazada,6 Wahid Majrooh,7 Ahmad Jan Naeem,8 Jolene Skordis- Worral,9
Zulqar A Bhutta,10 Hassan Haghparast- Bidgoli,5 Fahrad Farewar,7 Isabelle Lange,3
William Newbrander,11 Ritsuko Kakuma,12 Teri Reynolds,13 Ferozuddin Feroz8
Practice
To cite: SaeedzaiSA,
BlanchetK, AlwanA,
etal. Lessons from the
development process of
the Afghanistan integrated
package of essential health
services. BMJ Glob Health
2023;8:e012508. doi:10.1136/
bmjgh-2023-012508
Handling editor Seye Abimbola
►Additional supplemental
material is published online only.
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Received 4 April 2023
Accepted 6 August 2023
For numbered afliations see
end of article.
Correspondence to
Dr Karl Blanchet;
karl. blanchet@ unige. ch
© Author(s) (or their
employer(s)) 2023. Re- use
permitted under CC BY- NC. No
commercial re- use. See rights
and permissions. Published by
BMJ.
ABSTRACT
In 2017, in the middle of the armed conict with the
Taliban, the Ministry of Public Health decided that the
Afghan health system needed a well- dened priority
package of health services taking into account the
increasing burden of non- communicable diseases and
injuries and beneting from the latest evidence published
by DCP3. This leads to a 2- year process involving data
analysis, modelling and national consultations, which
produce this Integrated Package of Essential health
Services (IPEHS). The IPEHS was nalised just before the
takeover by the Taliban and could not be implemented.
The Afghanistan experience has highlighted the need to
address not only the content of a more comprehensive
benet package, but also its implementation and nancing.
The IPEHS could be used as a basis to help professionals
and the new authorities to dene their priorities.
INTRODUCTION
Despite an increasing number of armed
conflict attacks on civilians since 2015,
Afghanistan is on the path to universal health
coverage (UHC).1 Between September 2017
and August 2021 (prior to the arrival of the
Taliban in power), the Ministry of Public
Health (MoPH) set up context- specific
health, disease and inter- sectoral priorities.
This work was carried out within the frame-
work of Afghanistan’s National Health Policy
2015–2020,2 which includes revising its basic
package of health services (BPHS) and essen-
tial package of health services (EPHS) using
data from a number of national surveys,
reports, journal articles, a costing study and
the strengthening of coordination and coop-
eration with key partners and line ministries.
This work was finalised prior to the arrival of
the Taliban regime in August 2021 and was
not implemented by the Taliban regime.
The context for the development of a
revised health package is one in which the
Afghan government, since 2002, has achieved
substantial improvements in the health status
of its population despite serious episodes
of insecurity. Between 2000 and 2017, the
maternal mortality ratio reduced from 1100
to 638 deaths per 100 000 live births,2 and
under- five mortality has reduced from 257
to 55 per 1000 live births between 2000 and
2018.3
There is clear evidence that the high level
of insecurity in some provinces during the
pre- Taliban regime period had a negative
effect on the delivery and coverage of health
services, especially for maternal health and
childhood vaccines,4 which was later further
exacerbated by sanctions post takeover by
the Taliban government. Although all prov-
inces in the country increased the coverage
of maternal and child health services between
2005 and August 2021,5–7 there remained
significant differences between the poorest
and the wealthiest populations, between rural
and urban areas, and between provinces in
terms of health outcomes and utilisation and
coverage of health services.8 9 Direct out- of-
pocket expenditure by households was also
high nationally, accounting for 76.5% of total
health expenditure in 2018. Donors and the
SUMMARY BOX
⇒The development of a priority package in a country
requires evidence and political negotiation.
⇒In Afghanistan, the leadership from the Ministry of
Public Health helped build trust, ownership and con-
sensus amongst national actors.
⇒Afghanistan requires to introduce basic manage-
ment of diabetes and hypertension and emergency
care to better address the current burden of disease.
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government contributed to 19.7% and 3.9% of total
health expenditure in 2018, respectively.10
Key weaknesses in population health observed in
Afghanistan since 1990 were the high burden of commu-
nicable diseases, poor status or maternal and newborn
health, nutritional conditions and largely neglected
non- communicable diseases (NCDs).11 Among NCDs,
ischaemic heart disease, congenital defects and cerebro-
vascular disease all ranked among the leading causes of
premature death,12 with the additional high burden of
mental health disorders.13 14
In 2014, injuries from conflict and road injuries ranked
second and fifth, respectively, as causes of premature
death.11 Furthermore, deaths from conflict and terror
notably rose by almost 1200% between 2005 and 2016.12
2017 recorded the highest number of civilian casual-
ties from suicide and complex attacks in a single year
in Afghanistan since the United Nations mission in the
country began systematic documentation of civilian casu-
alties in 2009. Suicide and complex attacks accounted
for 22% of all attacks with 16% of the casualties taking
place in Kabul in 2017. In just one attack in the city on
31 May 2017, over 200 people were killed and nearly 600
injured.15
Priority health packages in Afghanistan
In 2001, after the end of the first Taliban regime, the
MoPH had the challenging task of rebuilding the health
system including how best to address the key health
challenges in the country; especially given that its popu-
lation’s maternal mortality and child mortality rates
represented the highest mortality rates in the world.16
In 2002/2003, the MoPH designed a unique package of
health services that helped bring coherence among the
health stakeholders in what was then a fragmented health
system. Towards the end of 2003, the MoPH supported by
its international partners, put in place the BPHS for the
primary healthcare level throughout the country. This
was followed in 2005 by the Essential Package of Health
Services (EPHS) for hospitals up to provincial level.17
The MoPH and health economists included in the
Expert Committee advising the MoPH estimated that
US$235M were spent by government and donors on
the BPHS and EPHS in 2018, equivalent to US$6.7 per
capita. The BPHS accounted for 72% (US$172M) of total
spending, whereas the EPHS accounted for around 28%
(US$63M) of total spending.18 Maternal and child health
accounted for around 45% of total BPHS spending.
Combined, government and donor spending on the
BPHS and EPHS averted an estimated 1.04M disability-
adjusted life years (DALYs). Almost 60% (605 000) of
DALYs averted by the BPHS and EPHS were related to
maternal and child health interventions.19
In 2018, the MoPH decided that the BPHS and EPHS
needed revising in light of the increase burden of disease
since 2006 related to NCDs (+2.5% annually) and inju-
ries (+4.4% annually), the international drive towards
UHC.20 and the publication of DCP3.21 In August 2021
(see figure 1), the new priority package, the Integrated
Package of Essential Health Services (IPEHS) was
finalised.
PRIORITY SETTING PROCESSES
The various trade-offs
The difficult decisions made in Afghanistan when starting
working on the IPEHS in 2018 were about responding
both to the epidemiological transition and level of
violence generated by armed conflict, while maintaining
gains in maternal and child health, ensuring equitable
Figure 1 The timeline of the development process of the IPEHS in Afghanistan. DCP3, Disease Control Priorities 3; IPEHS,
Integrated Package of Essential Health Services; LSHTM, London School of Hygiene and Tropical Medicine; MoPH, Ministry of
Public Health; UCL, University College London, universal health coverage.
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access to interventions and providing financial protec-
tion—within a highly constrained government and donor
budget envelope. Two key questions for the MoPH guided
the priority setting process. First, in the current BPHS
and EPHS, which interventions are no longer justified as
a top priority and which additional health interventions
are needed? Second, how to ensure the new package of
health services is accessible to the most underprivileged
that is, the poorest and the groups of populations living
the furthest from primary healthcare facilities?
Priority setting in Afghanistan between 2028 and 2021
was about making trade- offs not only between different
health interventions from different disease groups but
also between health services, public health interventions
and interventions tackling determinants of health. These
decisions carried with them value judgements and effi-
ciency (cost- effectiveness)- equity trade- offs. A priority
setting process usually takes place in an environment
where societal values are at stake and where tensions
exist between different perspectives and interests.22 This
process required legitimacy in order to gain any prospect
of public and political acceptance. As a result, all decision
was justified with rigorous documentation to make sure
that every step in the process was cumulative from the
previous one.23
In terms of governance, the MoPH, led by the Minister
of Public Health, drove the revision process. In their role
of overseeing this activity, the MoPH core team created
and managed nine in- country Working Groups and ‘inte-
grated expert opinion from members of the Ministry
and the local stakeholder community including inter-
national organisations such as United Nations agencies.
In Afghanistan, nine multistakeholder Working Groups
were set up according to health domains (reproductive,
maternal, child and adolescent health; mental health;
surgery; cardiovascular health; infectious disease; surgery;
cancer; palliative care; rehabilitation and inter- sectoral
policy) to provide expertise in reviewing the shortfalls
in the BPHS and EPHS. An advisory mechanism in the
form of an international Expert Committee was put in
place to maximise the use of data and evidence, ensure
the adequacy of the methodology, encourage creativity
in data analysis and provide accountability for use of the
results by the Afghan government as well as by national
and global stakeholders’.[24 Page 3]
A multi-criteria approach
MoPH adopted a multicriteria approach to enable them
to have a fair, transparent and mutual process to set prior-
ities.24 This approach was based on the following princi-
ples: (1) use of the latest global and national evidence
on burden of disease and cost- effectiveness of interven-
tions, (2) well- defined selection criteria agreed by all key
stakeholders, (3) transparent and documented process
of selecting interventions and (4) recognition that deci-
sions made are reasonable, combining both analysis of
evidence and expert discussions.
The selection criteria defined by the Expert Committee
in May 2018 to guide decisions of MoPH and experts
included the following: (1) effectiveness: What has been
proven to work? (2) local feasibility: local resources exist
to deliver? Are there staff in place? Are they trained? Is
the intervention supported by existing infrastructure? (3)
affordability: Are new drugs and equipment required? Is
there a large setup cost?; and (iv) Equity: Will the inter-
vention improve access to care? For whom?
The Expert Committee and MoPH also agreed on a
set of priority conditions and risk factors to address the
current burden of disease in Afghanistan. The priority
conditions included reproductive, maternal, newborn
and child health, injuries (conflict and road traffic acci-
dents), mental health (substance use, suicide, posttrau-
matic stress disorder), cardiovascular diseases (heart
attack, stroke), undifferentiated emergency presenta-
tion (difficulty breathing, shock, meningitis, diarrheal
disease, lower respiratory diseases) and diabetes. The
priority risk factors identified included undernutrition,
over- nutrition, smoking, water sanitation and hygiene, air
pollution and hypertension.
The MoPH designed a flexible process to examine
in- depth the bigger picture that is internal and external
to the setting of priorities by the institution to reflect the
connection and relationship between the different parts
of the health system, and in doing so:
1. MoPH research teams conducted an analysis of the
health needs and the health system capacity.
2. An expert committee was established, chaired by the
Minister of Public Health and composed of 12 nation-
al and international experts including from the DCP3
task force.
3. Nine local working groups were formed (one for each
of the nine health volumes of DCP3),21 to create an
initial draft of priority interventions based on field ex-
perience.
4. A number of opportunities created for a wide range
of stakeholders to help decide the priorities through
consultative workshops and meetings with NGOs, UN
agencies, Donors and Presidential office.
5. Defined clear selection criteria for the setting of prior-
ity interventions and opportunities.
6. Costed the existing and new package of health services
and the identification of relevant global cost- effective
interventions.
7. Projections of the fiscal space between 2018 and 2030
conducted on different scenarios.
8. Enhancing advocacy and negotiation to mobilise do-
mestic revenue.
9. Rigorously examined the short- term and long- term
implications of the new package of health services and
developing relevant implementation approaches and
systems including a tailored monitoring and informa-
tion system.
At the same time, MoPH determined which of the DCP3
early intersectoral policy interventions was addressed as
a priority using standardised and transparent criteria.
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It also worked on minimising financial risks to people,
especially the poor in Afghanistan.
The priority setting process was conducted within
the available and projected fiscal space. According to
the Ministry of Finance and the 2020 National Health
Accounts, more than half (52%) of the national budget
was funded by foreign aid, 44.8% by domestic revenue
and 3.2% by loan.25 From the total budget, 5% was allo-
cated to MoPH, of which about 79% was funded by donors
covering the BPHS and EPHS. Through the MoPH’s
budgetary prospect exercise, three possible realistic
scenarios for budget expansion were developed in order
to cover the potential expansion of services provided
under the High Priority Programme for Afghanistan.26
Based on stable support from international donors,
stable economic growth and a slight reduction in out of
pocket expenditure, it was estimated that in a low variant
projection, the per capita expenditure will increase by
one per cent per year. In a medium variant projection,
it was estimated that the total health spending per capita
will increase by 5%, and in a high variant projection by
8%.26 Of course, these projections did not include the
scenario that the Taliban would take over in August 2021.
ANALYSIS AND TOOL
The use of DCP3 data
The third edition of Disease Control Priorities published
between 2015 and 2018 in nine volumes provides a review
of evidence on cost- effective interventions to address the
burden of disease in low and middle- income countries.21
It does so by drawing on systematic reviews of economic
evaluations, epidemiological data and clinical effective-
ness studies, and on the expertise and time of over 500
authors.27 While DCP3 data are generally considered
thorough and to have been constituted in a transparent
manner, considerable adaptation must be undertaken
when applying it at the country level, especially in those
countries, like Afghanistan, where contextually adapted
evidence was especially needed given the complexity
brought about by sectarian violence and armed conflict.
National health officials are advised by DCP3 that its
packages of interventions needed to be modified based
on local priorities, and that country- specific analyses as to
costs and impact should be carried out.
To inform each health system building block, team
members consulted additional sources, including the
most recently available national health information
systems data and results from the28 Mental Health survey
and other national surveys.29 To develop the list of inter-
ventions, working groups compared the DCP3 list of
interventions with the existing BPHS and the EPHS. The
MoPH decided that the revised package of health services
would be unique from community level to provincial
level—instead of two distinct packages. This involved
prioritising the interventions in DCP3 and assigning
them to the different categories of health system level,
categorised by health facility type. Contextual knowledge
and specialist assessment as to which interventions would
be possible given government and partner support at
each level were critical for this task.
DALY-driven rationale
DALYs are a measure of the burden of disease accounting
for the number of years lost due to ill health, disability or
early death. DALYs ‘measure the gap between a popula-
tion’s health and a hypothetical ideal for health achieve-
ment’30 and are used in setting health research priorities,
identifying disadvantaged groups and targeting health
interventions. While estimates, projections and model-
ling that are based on mortality—how many deaths
could be averted due to a health service being offered—
are popular and compelling, unlike DALYs they do not
capture morbidities such as chronic diseases, mental
health, injuries and disabilities, that will have an impact
on quality of life.
The Expert Committee took the decision to use DALYs
through the Health Interventions Prioritisation tool
(HIPtool),31 a health resource optimisation tool, using
context- specific data on burden of disease and inter-
vention cost- effectiveness to help stakeholders iden-
tify funding priorities and targets. The reference point
of this expert committee consultation, the Essential
Universal Health Coverage package published by DCP3,
is based on evidence of cost- effectiveness, presenting data
in the form of ‘cost per DALY averted’ (an incremental
cost- effectiveness ratio, ICER).21 DALYs provided a single
measure for which to compare interventions across the
entire BPHS and EPHS packages. Given the amount of
diseases and interventions considered, it is important to
note that results might have been less clear to interpret if
a variety of outputs were used.
Summary of analysis ndings
In the first comprehensive list, 149 interventions were
included for consideration. For the international expert
committee meetings, HIPtool generated estimates of
DALYs averted by: (1) existing spending, (2) additional
spending projections based on fiscal space assessments,
(3) scaling- up existing Reproductive, Maternal, Newborn
and Child Health (RMNCH) interventions in the package
and (4) optimised spending based on intervention cost-
effectiveness and burden of disease. The HIPtool opti-
mised spending scenario supported recommendations
on the inclusion of emergency and trauma care as well as
cost- effective mental health interventions in the IPEHS
package.
The IPEHS was organised by seven platforms of the
health system: (1) community health post; (2) mobile
health teams (MHT); (3) subhealth centre (SHC); (4)
basic health centre (BHC); (5) comprehensive health
centre (CHC); (6) first referral hospital and (7) second
referral hospital. In order to highlight the level of inte-
gration and continuum between the various levels of the
health system, the interventions were defined by level
based on the resources and skills available at the level with
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an explicit link with the previous or next level of referral
(see Annex 1 for the full list of IPEHS interventions).
Nine domains were defined to help structure the inter-
ventions: (1) reproductive, maternal and newborn health;
(2) child and adolescent health and development; (3)
infectious diseases; (4) chronic NCDs; (v) mental, neuro-
logical and substance use disorders; (vi) emergency care;
(vii) surgical interventions; (viii) palliative care and (ix)
rehabilitation.
These nine domains were completed by 11 population-
based interventions such as mass media campaign
promoting healthy diet and physical exercise or prepared-
ness strategy in case of infectious disease outbreak.
Finally, the IPEHS was composed of 15inter- sectoral
interventions such as regulate transport, industrial,
power and household generation emissions to reduce air
pollution or ban smoking in public places.
Cost of IPEHS
Healthcare access, quality and outcomes vary widely
across geographies in Afghanistan. Variations in the
financing and provision of healthcare services along with
population displacements, geographic remoteness, diffi-
cult terrain, sociocultural isolation and health awareness
contribute to these differences. To address this, a number
of provinces were carefully selected for inclusion in the
cost analysis to achieve good geographic spread and suffi-
cient representation from each region: Dikundi, Faryab,
Takhar, Nangarhar, Paktya, Urzgan and Herat based on
geographical representations from Central, North West,
North East, East, South, South West, and West, respec-
tively.
The BPHS cost analysis was carried out using the Cost
Revenue Analysis Tool Plus (CORE Plus) for MHT, SHC,
BHC, CHC and district hospital (DH) levels of the health
system. Expenditure data were collected from NGOs
from 534 health facilities in seven selected provinces
in AFN currency, and it was converted to USD based
on an exchange rate of 2020 at 78 AFN.18 The studied
health facilities covered 21% of the total population in
2020. Provincial hospitals (PH) and higher levels of the
health system, for the EPHS, were costed separately using
hospital data.
The difference between the costs of BPHS and EPHS
and IPEHS 2021 was also assessed to understand the
costs of supplementary interventions under IPEHS 2021.
The health facilities were categorised into two groups—
primary healthcare services and secondary healthcare
services, which included PH. The total additional cost
of the supplementary interventions was estimated at
US$39 141 581. The additional costs of IPEHS compared
with BPHS at the primary healthcare level (Community
level, Mobile Health Tesm, sub- Health Centre, BHC,
CHC, DH) and compared with EPHS at secondary health-
care level (PH and above) were US$30 334 630 and US$8
808 951, respectively. In other words, primary healthcare
accounted for 77.5% of the total required increase in
IPEHS cost, whereas the cost of the additional secondary
service share was 22.5% of the total cost. The overall
average per capita cost of IPEHS was US$6.9.18
METHODOLOGICAL LIMITATIONS
Getting access to data was a tremendous challenge for the
working groups and the international expert committee.
As a result, consensus panels were applied to capture
expert opinion. This approach can synthesise expert
opinion when other data are not available. However,
such method is prone to various types of biases. There-
fore, more studies on benefit- incidence analysis and
cost- effectiveness were necessary for future exercises in
Afghanistan to better assess implications on equity and
allocative efficiency.
Given the number of interventions, project budget
and time constraints to meet a policy reform window,
no cost- effectiveness study was conducted in Afghanistan
for this prioritisation exercise. HIPtool drew on national
cost- analysis data, available by intervention and cost-
effectiveness data published by DCP3 to estimate existing
and potential population health impact for each inter-
vention and for different health packages as a whole.
One justification was that DCP3 volumes had just been
released providing up- to- date reviews on effectiveness
and cost- effectiveness of health interventions at global
level—with a focus on low and lower middle income
countries. The analysis of these reviews was discussed
in the international expert committee to verify the rele-
vance of the DCP3 findings. Using existing evidence
and HIPtool enabled us to carry out analyses to quantify
trade- offs of different decisions, in terms of population
health, iteratively throughout the process and to inform
three key discussions on IPEHS design.
The prioritisation exercise was a heavy process mobil-
ising a lot of resources in country and outside. It required
more than 2 years to finalise the high- priority package
and make sure that concerned parties (senior staff at
MoPH, provincial authorities, development partners)
were properly engaged. One possibility of reducing these
transaction costs could be to regularly update the priority
package and organise a review of the package around
every 3 years or in line with 5- year national plans.
This prioritisation process greatly benefited from the
experience of the two successive ministers as Afghanistan
had conducted a similar exercise in 2012. With the arrival
of the Taliban, many individuals with high level expertise
in Afghanistan left the country. The revision or conduct
of such processes in the near future will require political
willingness and rebuilding expertise in the country on
health economics and public health as well as availability
and modality of resource allocation.
LESSONS LEARNT
The prioritised package, IPEHS, contained 144 health
interventions and 14 intersectoral interventions that
address the burden of communicable diseases, repro-
ductive, maternal, newborn and child health, chronic
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diseases and injuries due to armed conflict. It included
for the first time cost- effective services for chronic
conditions, such as diabetes and hypertension, emer-
gency trauma care and palliative care, while main-
taining focus on addressing the high maternal and
neonatal mortality rates. The package was finalised
in August 2021, just before the Taliban took over the
country.
The IPEHS development was supported by Bill and
Melind Gates Foundation as well as UN agencies and
Sehatmandi donors (World Bank, USAID, European
Union, Canada). While there was high- level commitment
at the MOPH, the budgetary prospect was very limited
and it was met with hesitancy from international donors.
The emergence of a new package raised questions among
donors on the financial capacity of the government to
increase financial commitment to cover the new interven-
tions and ensure no increased out- of- pocket payments.
A set of challenges and needs were identified in revising
the health benefits package in Afghanistan. The team
faced difficulties in knowing how and when to start the
process of revising the BPHS, citing lack of clear vision
from the start of what the government thought was most
needed in Afghanistan. There was also a clash between
the political and health agendas, which led to increased
pressure to deliver the revised package before the 2019
elections. This relative short timeline (18 months) to
deliver a full revised package leads to a shortened consul-
tation process in country expressed by national stake-
holders as a missed opportunity to create ownership.
While several governmental departments and provincial
health directors were involved in the process of revising
the benefit package, there was a realisation that infor-
mation on the prioritised package was not cascading
effectively from top leadership across the health system.
Two national consultations were organised in February
and May 2021 to overcome this communication gap and
receive feedback on the revised package. As a result,
the 2019 IPEHS was left aside after the departure of the
Minister. It was not until the end of the 2020 that there
was revived interest in the IPEHS by the President of
Afghanistan. The MoPH decided to finalise the IPEHS by
emphasising the national consultation process. Univer-
sity of Geneva was called back to provide guidance and
help integrate feedback from national stakeholders into
the IPEHS, which resulted in the 2021 IPEHS. A detailed
account and review of the priority setting process as a
whole was published by Lange et al.23
Change of MoPH leadership in the middle of the
project in 2019 impeded the finalisation of costing the
package, its implementation and sustainability. Inade-
quate commitment and engagement of the Ministry of
Finance, low budget allocation and overdependency
on donor funding remain major challenges for UHC in
Afghanistan. In 2021, the costing of the IPEHS was final-
ised, but this time, the arrival of the Taliban prevented
the MoPH and University of Geneva from developing a
realistic implementation plan.
Since the Taliban took control over Afghanistan, imple-
mentation of the IPEHS is on hold due to the current
political situation. The experience in revising the Afghan-
istan IPEHS highlighted the need to address not only the
development of a more comprehensive benefit package
but also its implementation, with careful deliberation on
the pre- requisites for implementing and financing the
HBP and health systems strengthening. The IPEHS can
be used as a foundation to define a new priority package
under the Taliban rule.
Author afliations
1M&E HIS, Ministry of Public Health, Kabul, Afghanistan
2Global Health Development, University of Geneva Faculty of Medicine, Geneva,
Switzerland
3Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine,
London, UK
4Health System Development, WHO Country ofce for Afghanistan, Kabul,
Afghanistan
5Institute for Global Health, University College London, London, UK
6Geneva Centre of Humanitarian Studies, Faculty of Medicine, University of Geneva,
Geneve, Switzerland
7Ex- Ministry of Public Health, Kabul, Afghanistan
8Ministry of Public Health, Kabul, Afghanistan
9Institute for Global Health, UCL, London, UK
10Centre for Global Child Health, The Hospital for Sick Children, Toronto, Ontario,
Canada
11Management Sciences for Health, Cambridge, Massachusetts, USA
12Centre for Global Mental Health, London School of Hygiene & Tropical Medicine,
London, UK
13Integrated Health Services, World Health Organization, Geneva, Switzerland
Twitter Karl Blanchet @BlanchetKarl, Ala Alwan @AlaAlwan1, Neha S Singh
@neha_s_singh and Wahid Majrooh @wahidmajrooh
Acknowledgements We thank all the technical working groups in Afghanistan
who reviewed each intervention.
Contributors AS and KB drafted the paper. All co- authors contributed to the
design of the study and contributed to the paper.
Funding This study was funded by Bill and Melinda Gates Foundation, Grant
OPP1177572.
Competing interests None declared.
Patient consent for publication Not applicable.
Ethics approval Not applicable.
Provenance and peer review Not commissioned; externally peer reviewed.
Data availability statement Data are available upon reasonable request.
Supplemental material This content has been supplied by the author(s). It has
not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been
peer- reviewed. Any opinions or recommendations discussed are solely those
of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and
responsibility arising from any reliance placed on the content. Where the content
includes any translated material, BMJ does not warrant the accuracy and reliability
of the translations (including but not limited to local regulations, clinical guidelines,
terminology, drug names and drug dosages), and is not responsible for any error
and/or omissions arising from translation and adaptation or otherwise.
Open access This is an open access article distributed in accordance with the
Creative Commons Attribution Non Commercial (CC BY- NC 4.0) license, which
permits others to distribute, remix, adapt, build upon this work non- commercially,
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use is non- commercial. See:http://creativecommons.org/licenses/by-nc/4.0/.
ORCID iDs
KarlBlanchet http://orcid.org/0000-0003-0498-8020
Neha SSingh http://orcid.org/0000-0003-0057-121X
Gerard JosephAbou Jaoude http://orcid.org/0000-0001-6022-3036
on September 29, 2023 by guest. Protected by copyright.http://gh.bmj.com/BMJ Glob Health: first published as 10.1136/bmjgh-2023-012508 on 28 September 2023. Downloaded from

SaeedzaiSA, etal. BMJ Glob Health 2023;8:e012508. doi:10.1136/bmjgh-2023-012508 7
BMJ Global Health
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