In Afghanistan following the Taliban takeover in mid-2021, Sharia-led restrictions on female mobility and the health workforce have hindered access to health services for women and children. Under five mortality is high, according to a 2023 national survey. To address this, Abt Global is working with USAID through the Local Health System Sustainability Project (LHSS) to restore access to high-quality, affordable healthcare for urban, low-income communities—particularly women—by providing technical and grant support to six local private health organizations.
By using the Equity Tool to better understand relative wealth quintiles of clients, grantees can target health subsidies equitably, making services more affordable and accessible for those most in need. This innovative approach was recognized at the 8th Global Symposium on Health Systems Research in November 2024, with the Davidson Gwatkin Equity Measurement Prize.
Needing a more equitable process for administering health subsidies
The private health sector in Afghanistan has the potential to improve access to affordable care for urban populations. Since high user fees and medical costs are significant barriers, especially for low-income individuals, LHSS works with six local private health organizations in scaling up their patient subsidy schemes and increasing equitable access to healthcare for disadvantaged people.
However, the subsidy selection processes lacked objectivity and clear eligibility criteria. “Determining the level of subsidy offered to various patients relied on considerable subjectivity,” says Soumitra Ghosh, the Chief of Party for LHSS Afghanistan. LHSS explored several poverty assessment tools, which would be used to establish an evidence base for administering the subsidy schemes. The team chose the Equity Tool, developed by Metrics for Management, for its simplicity and ease-of-use in measuring relative wealth quintiles in both urban and rural populations, based on Afghanistan-specific measures and databases.
Piloting the Equity Tool in grantee facilities
LHSS worked with private sector health providers to pilot the tool in four health facilities—three in Kabul and one in Nangarhar. During the pilot phase, all 445 patients who sought financial assistance were screened using the tool. This helped the team to determine the patients’ wealth quintiles. Throughout the process, the team also gathered feedback from health providers on their experience using the tool.
The Equity Tool determined that most patients—70 percent—who were screened among those seeking financial assistance for health services fell within the bottom three wealth quintiles. Following their own criteria, private sector providers offered subsidies to 94 percent of patients and denied 6 percent.
However, more patients from the bottom three wealth quintiles were denied subsidies than their counterparts in the top two wealth quintiles. Just as notably, at least 29 percent of patients who received subsidies came from the top two wealth quintiles.
“The findings supported LHSS's observation that there was a lack of objectivity and a widespread inconsistency in targeting and granting subsidies in existing programs,” explains Soumitra Ghosh, the Chief of Party for LHSS Afghanistan. “We recommended that they apply the tool going forward, to more rationally allocate subsidies, using USAID funding, to patients in the lowest wealth brackets, prioritizing women, in both urban and rural areas.”
Following the pilot, all six private sector health providers have adopted the tool and apply it consistently in assessing distribution of health subsidies. LHSS adapted the tool and translated it into Dari and Pashtu for community-based use, while tracking monthly reporting through the tool’s dashboards.
LHSS Afghanistan and partner organizations are working towards building and strengthening sustainable private sector models while addressing the urgent needs of priority populations—primarily women and children—in mainly urban and peri-urban areas of five of Afghanistan's most populous provinces: Balkh, Herat, Kabul, Kandahar, and Nangahar. This work builds on the achievements of the USAID Sustaining Health Outcomes through Private Sector Plus (SHOPS Plus) Project, (2016 to 2022), also led by Abt.
Overall, the grants that LHSS Afghanistan has provided to private sector organizations have resulted in 13.2 million people receiving social and behavior change messages to increase the uptake of and access to critical health products and services. A total of 939,000 patients—65% of whom are women—received essential health services, while 445,000 low-income clients benefited from free or discounted services through integrated financing schemes. Additionally, over 30,000 children under five years of age received nutrition supplementation.
Since 2016, Abt has been collaborating with local partners in Afghanistan to advance their organizational priorities and strengthen the country’s health systems so they are more resilient and sustainable. We are committed to working with the private sector to expand access to high-quality health services for all, drawing on our strong relationships with local governments and deep understanding of the intricacies of the private health sector to achieve positive health outcomes.
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