Human resources management for communicable diseases in Afghanistan

Abstract

Background

Effective management of communicable diseases (CDs) requires a professional, motivated, and dedicated health workforce. Afghanistan, which bears a high burden of CDs, faces significant challenges in maintaining such a workforce. This study aims to strategically analyze human resource management (HRM) for CDs in Afghanistan and to propose appropriate strategic solutions.

Methods

A qualitative study was conducted between February 27 and September 21, 2024 using interpretative phenomenology (IP) through semi-structured interviews with 49 experts, including policymakers, managers, service providers, and NGO officers within Afghanistan’s health system. Data were analyzed using a framework analysis approach guided by a SWOT (Strengths, Weaknesses, Opportunities, and Threats) framework to identify factors related to the health workforce in CDs management, including challenges and potential solutions.

Results

The study identified 15 strengths, 16 weaknesses, 8 opportunities, 13 threats, and 23 potential solutions related to HR for managing CDs. Key strengths included an established network of community health workers and recruitment through online platforms. Major weaknesses involved inequitable distribution of health personnel, imbalance between supply and demand, shortage of qualified managers, insufficient female health workers, lack of CD specialists, and inadequate salaries. Opportunities included the presence of a young health workforce, while key threats were brain drain, resource limitations, and restrictions on women’s education. Proposed solutions emphasized improving retention strategies, increasing recruitment budgets, promoting female education, and raising salaries for health professionals.

Conclusions

Effective management of CDs in Afghanistan requires a knowledgeable, sufficient, and well-supported workforce. Addressing workforce challenges through strategic planning, recruitment, and retention initiatives—guided by insights from the SWOT analysis—can strengthen the health system’s capacity for sustainable CD control.

Introduction

The health workforce is widely recognized as a critical asset within any healthcare system, as no organization can function effectively without skilled personnel [1]. Expanding service coverage and ensuring the right to quality healthcare depends fundamentally on a competent, motivated, and dedicated workforce [2]. Effective management of CDs relies on such a workforce, particularly given the persistent burden of these diseases and their frequent emergence and reemergence. Tragically, many healthcare workers lose their lives while combating public health threats; during the first year of the COVID-19 pandemic alone, approximately 115,000 healthcare workers died [3].

In addition to professionalism and commitment, adequate staffing levels are essential. The shortage of healthcare personnel is a global concern, with the World Health Organization (WHO) projecting a shortfall of approximately 10 million health professionals by 2030, primarily in low- and lower-middle-income countries (LMICs) [2]. The migration of healthcare workers to industrialized nations, driven by higher salaries and better working conditions, further exacerbates shortages in their home countries [4].

Afghanistan, a mountainous LMIC covering 652,860 square kilometers with a population of 43.1 million—73.5% of whom reside in rural areas [5]—faces profound HR challenges. The country’s Human Development Index (HDI) is 0.462, ranking 193 out of 204 countries [6]. Afghanistan has only 8.7 doctors, nurses, and midwives per 10,000 population [7], far below the WHO-recommended minimum of 25 per 10,000 [8]. Approximately 30,000 community health workers (CHWs) provide the Basic Package of Health Services, managing common illnesses such as tuberculosis, malaria, acute watery diarrhea, and upper respiratory infections [9, 10]. The country has more than 40 public and private medical schools, collectively graduating around 5,000 health professionals annually [11] (Table 1).

Table 1.

Total number of health professionals in Afghanistan in 2021 (latest available data) [7]

Health profession	Number of health professionals
	Female	Male	Total
Medical specialist	45	337	382
General physician	305	1239	1544
Midwife	2941	43	2984
Nurse	970	2778	3748
Vaccinator	960	2041	3001
Other	3613	9990	13,605
Total	8834	16,428	25,262

The burden of CDs in Afghanistan remains high. Tuberculosis (TB), malaria, acute respiratory infections, acute watery diarrhea, HIV/AIDS, viral hepatitis, measles, COVID-19, brucellosis, typhoid fever, and Crimean-Congo hemorrhagic fever (CCHF) are among the most prevalent conditions [12]. Afghanistan’s mountainous terrain and limited infrastructure severely hinder prevention, control, and timely treatment. In many remote areas, health services are primarily delivered by CHWs, health post staff, and other local personnel who often lack adequate medical knowledge and training. Many CHWs are elderly or illiterate, limiting their ability to comprehend new information, conduct effective home visits, and fulfill their responsibilities [13].

CHWs are tasked with administering Directly Observed Treatment, Short Course (DOTS) for TB [14] and prescribing antimalarial drugs. Improper use or prescription of anti-TB medications can lead to multidrug-resistant TB (MDR-TB), a serious challenge to global TB control [15]. In addition, many vaccinators fail to maintain cold chain standards or administer vaccines correctly, undermining efforts to eradicate polio and other vaccine-preventable diseases. Midwives often lack access to refresher training on infection prevention for mothers and newborns, and most hospitals face an acute shortage of specialists in communicable diseases.

The shortage of healthcare workers, particularly women, further compounds these challenges. Since August 2021, approximately 450,000 female students have been forced to suspend university studies due to the ban on women’s education, including many pursuing health-related fields [16]. Additionally, a significant number of healthcare professionals have left the country since 2021, weakening an already fragile health system.

Given these challenges, effective HRM is essential for controlling CDs. Policymakers urgently need to strengthen workforce planning, recruitment, and retention strategies to build and sustain a competent health workforce. Accordingly, this study aims to analyze the current HR situation for CDs management in Afghanistan, identify its strengths, weaknesses, opportunities, and threats (SWOT), and propose practical solutions to address existing HRM challenges.

Method

This study employed a qualitative methodology using Interpretative Phenomenological analysis, which aims to understand individuals’ beliefs, experiences, attitudes, behaviors, and interactions, producing rich, non-numerical data [17, 18]. Interpretative Phenomenology focuses on participants’ subjective experiences and their personnel perceptions of events, making it particularly suitable for examining the complex and multifaceted issues surrounding CDs management in Afghanistan.

Data collection

Semi-structured interviews were conducted to obtain a comprehensive and nuanced strategic analysis of Afghanistan’s CDs management system, based on the six building blocks of the WHO health system framework (2010) [19]. This article specifically reports on the SWOT (Strengths, Weaknesses, Opportunities, and Threats) analysis of the health workforce building block, encompassing its key sub-sections: human resource (HR) planning, recruitment, education and training, employee relations, performance appraisal, and compensation [20].

An interview guide was developed to explore participants’ perspectives on the strengths, weaknesses, opportunities, and threats of the CD management system, as well as potential solutions. Interviews were conducted in participants’ workplaces or homes, or via mobile phone and online platforms when in-person meetings were not feasible. The average interview duration was approximately 25 min. Interviews were conducted in local languages and subsequently translated into English for analysis, and all sessions were audio-recorded to ensure accuracy.

A pilot study involving 10 participants was conducted between February 27 and April 16, 2024, to test and refine the interview guide, assess the clarity and relevance of the questions, and ensure the interviewer’s ability to engage effectively with participants. Following the pilot, a total of 49 in-depth interviews were conducted from February 27 to September 21, 2024. Purposive and snowball sampling were used to ensure diverse representation among experts, including policymakers, managers, NGO officers, service providers, and staff from hospitals and health centers. Eligible participants were public health professionals with at least three years of experience in Afghanistan who provided informed consent. Data collection continued until saturation was reached—after 45 interviews, no new themes emerged. Four additional interviews were conducted to confirm comprehensive representation and data completeness.

Participant characteristics

As shown in Table 2, the majority of participants were male (95.9%), aged 30–40 years (34.7%), held master’s degrees (28.5%), and had 15–20 years of professional experience (28.5%). Participants were primarily policymakers (20.4%) and service providers (20.4%).

Table 2.

Demographic characteristics of the research participants (n = 49)

Variable	Frequency	Percent
Age
Less than 40	17	34.7
41 to 50 years	16	32.6
51–to 60 years	14	28.6
More than 60 years	2	4.1
Work experience
Less than 5 years	6	12.2
5 to 10 years	11	22.5
10 to 15 years	6	12.2
15–20 years	14	28.7
20–30 years	6	12.2
30–40 years	6	12.2
Sex
Male	47	95.9
Female	2	4.1
Level of education
Ph.D.	4	8.1
Master	14	28.5
MD	19	38.8
Specialist	10	20.4
BSC	1	2.1
Nurse	1	2.1
Job category
Policy maker	10	20.4
Service provider	10	20.4
Manager	10	20.4
NGO officer	7	16.3
Lecturer	10	20.4
Parliamentarian	1	2.1

Data analysis

Data were analyzed using a framework analysis approach, following seven stages: transcription, familiarization, coding, development and application of an analytical framework, charting, and interpretation [21]. All interviews were transcribed verbatim immediately after collection to preserve participants’ original meanings. During familiarization, transcripts were read multiple times to gain an in-depth understanding of the content and context. Initial codes were generated using the predefined sub-sections of the health workforce building block.

To ensure the validity and consistency of the analysis, a subset of transcripts was independently coded by two members of the research team. Any discrepancies in coding were discussed and resolved through consensus, and the coding framework was refined accordingly. Once agreement on the framework was achieved, it was applied to the remaining transcripts.

Codes were then organized into categories reflecting key themes aligned with the analytical framework. The finalized framework was systematically applied to all transcripts, and data were charted into matrices to identify patterns, relationships, and variations across participants. These patterns were subsequently synthesized and mapped onto a SWOT (Strengths, Weaknesses, Opportunities, and Threats) structure to facilitate a strategic analysis of the health workforce for CDs management in Afghanistan. Participant quotations are indicated with a “P” in the Results section.

Trustworthiness and ethical considerations

The research team strengthened the study’s validity through maximum diversity sampling, pilot interviews, prolonged engagement with participants, triangulation of perspectives, iterative comparison of data, and providing participants with a detailed explanation of the study’s purpose and procedures. Informed consent was obtained for participation and audio recording. Participation was voluntary, with the right to withdraw at any time, and all data were treated confidentially. The researchers’ perspectives were not incorporated during data collection, analysis, or reporting.

Results

The results of the analysis are presented across six key sub-sections representing the main domains of human resource management (HRM) in CDs control: (1) human resource planning, (2) recruitment, (3) education and training, (4) employee relations, (5) performance appraisal, and (6) compensation. All codes were classified and analyzed within these thematic domains. Table 3 presents a SWOT analysis derived from these qualitative findings, illustrating the strategic strengths, weaknesses, opportunities, and threats related to the health workforce and its sub-sections, along with proposed solutions.

Table 3.

Sub-themes and codes for health workforce required for CDs management system

	Strengths	Weaknesses	Opportunities	Threats	Solutions
HR planning	1. Existence of National Policy on Human Resources Development for health 2. Inclusion of CHWs as intermediaries between small communities and broader health care systems and 3. Existence of mobile teams	1. Inequitable distribution of HR 2. Imbalance between HR supply and demand and 3. Lack of professional top and middle level managers	1. Sufficient young health workforce in Afghanistan 2. Technical and fiscal aid of donors in HR planning	1. Brain drain 2. Lack of exact number of country’s population 3. Limitation of number of staff for MOPH by MOF and 4. Disruption of licensed health workforce by local layman	1. Developing a comprehensive healthcare workforce development plan 2. Obtaining an accurate or a close estimate of the country’s population 3. Developing better policies for fair distribution of health workforces by assessing demand and supply of HR, 4. Negotiating with the officials of the MOPH regarding the appointment of managers with experience and knowledge
HR recruitment	1. Recruiting health workforce through advertising in ACBAR website 2. Recruitment of CHWs based on WHO’s guidelines and 3. Recruitment of health workers based on merit	1. Shortage of health workforces, especially females 2. Lack of CDs professionals in remote areas and 3. Lack of job security	1. Existence of a wide job vacancy	1. Hiring employees based on friendship, nepotism and political group 2. Resourcing constraints 3. Lack of suitable living facilities for doctors in remote areas	1. Addressing shortage of HR by increasing the budget for hiring new health workforce, part-time employment of retirees with low salary and overtime of current employees 2. Correcting gender imbalance 3. Recruitment should be based on free competition and meritocracy and 4. Job security should be assured
HR education and training	1. Existence of the best CDs professionals 2. Existence of experienced and committed health workforce 3. Existence of CDs class with syllabuses related to the context of Afghanistan in the framework of the medical education curriculum and 4. Existence of on-job training and refresher programs for healthcare personnel	1. Shortage of super specialists in CDs 2. Outdated knowledge among health workers, and a high illiteracy rate among CHWs 3. Limited access to training opportunities inside the county and abroad and 4. Low quality medical education in private medical universities	1. Donors interest to train health workforces 2. Increasing the interest of youth in medical knowledge and careers in health	1- Banning the women’s education by the government 2. Cultural barriers of people that they don’t allow women to educate or work and 3. Funding cuts from international donors	1. Advocacy for female education 2. Updating curriculum and improving health workers’ knowledge 3. Expanding the on-job training of health workers programs in all hospitals 4. Increasing the skill and knowledge of medical students 5. private medical universities should be closely supervised and regulated 6. Promoting the use of new technologies such as telemedicine 7. Strengthening ties with international medical universities and 8. Replacing the older and illiterate CHWs with literate and professionals
HR relations	1. Good communication between health staff and managers and patients-providers and 2. Existence of a friendly work environment in the most health centers	1. Lack of conflict management in health centers and 2. High workload of staff and their burnout	1. Existence of mobile phone and internet for patient-provider communication	1. Ugly behavior of powerful people with medical staff and 2. Separation of male and female staff areas in hospitals mandated by new government legislation	1. Providing psychological and social support for health workers to reduce job burnout and 2. management of conflict between employees
HR performance appraisal	1. Existence of Performance Management Standard Operating Procedures in the framework of MOPH and 2. Existence of serious monitoring of staff to attend to their work regularly	1. Lack of recognition of the potential talents of employees and 2. Lack of commitment of some health workforce	1. The oppressive behavior of the government that the health work forces cannot fail to perform their duties	1. Inequity in salaries of health workers who fight the threats of CDs vs managers who work in comfortable offices	1. Increasing the control on the presence of health workforce in health facilities by installation of digital attendance devices in health centers and 2. Observing justice in salaries
HR compensation	1. Adequate salaries and other incentives for professors and lecturers in teaching hospitals and all health workers in NGOs and private sector hospitals	1. Inadequate salaries in most governmental health organizations and 2. Lack of employees’ loyalty due to lack of job security	1. People's respect for doctors and other health workers	1. Lack of medical courts	1- Increasing the salaries of first line fighters against CDs threats and creating incentives for them 2. Increasing the risk premium for technical staff and 3. Creating a supportive environment for healthcare workers

HR Human Resource, CHW Community Health Worker, ACBAR Agency Coordinating Body for Afghan Relief and Development, CD Communicable Disease, MOPH Ministry of Public Health

HR planning

The analysis revealed several contextual factors shaping HR planning for CD control in Afghanistan. Participants highlighted the existence of the National Policy on Human Resources Development for Health and the integration of CHWs as intermediaries between small communities and broader health systems as key strengths. CHWs were consistently described as the backbone of primary healthcare and essential actors in CD prevention and control. As one policymaker from the Ministry of Public Health (MOPH) explained, “In Afghanistan’s remote and hard-to-reach areas, where accessing healthcare services can be challenging, CHWs play a key role in various aspects of CD prevention, early detection, and treatment, reducing disability, and facilitating rehabilitation” (P38, policymaker, MOPH). The presence of mobile health teams serving rural and underserved populations was also viewed positively. A public health expert elaborated, “There are mobile health teams that deliver primary healthcare and immunization services for women and children in rural and remote provinces such as Nangarhar, Kunar, Nuristan, Kandahar, Helmand, Urozgan, Parwan, Sar-e-Pol, Bamyan, Paktika, Wardak, Nimroz, Herat, Badghis, and Jawzjan” (P03, public health expert).

However, significant weaknesses persist in HR planning. Participants emphasized the inequitable distribution of health workers across the country, with most concentrated in major cities. As an NGO officer observed, “Most health workers are based in cities like Kabul, Mazar-e-Sharif, Jalalabad, Herat, and Kandahar” (P34, NGO officer). Another concern was the imbalance between HR supply and demand. A policymaker noted, “According to estimates, there are about nine health workers for every 10,000 people in Afghanistan, but the WHO recommends at least 25 per 10,000” (P42, policymaker, MOPH). The absence of professional top- and mid-level managers was frequently cited as another major issue. A service provider remarked, “After the change in government, many top and mid-level managers were appointed from among religious leaders who unfortunately lack professional knowledge” (P47, service provider).

Despite these challenges, participants identified important opportunities, particularly the availability of a young and motivated health workforce and ongoing technical and financial support from international donors. A manager from a public health institute explained, “Every year, a significant number of doctors, nurses, technicians, and other health professionals graduate from public and private universities, all seeking employment opportunities” (P11, manager, public health institute).

Conversely, several threats were seen as undermining HR planning efforts. Chief among them was the large-scale migration of skilled professionals. An NGO officer stated, “Attracting talents back to the country remains difficult due to security concerns, children’s education—especially for girls—low salaries, and lack of recognition for their efforts. Unfortunately, the MOPH has no plan to address this” (P34, NGO officer). Another policymaker from the Center for Disease Control and Prevention (CDC) added, “Following the recent government change, there has been a significant exodus of experts—around 57,000 professionals from all sectors, including health, have left the country” (P35, policymaker, CDC). Additional challenges included the lack of accurate population data needed for HR forecasting, budget constraints imposed by the Ministry of Finance, and the interference of unqualified individuals practicing medicine. A university lecturer noted, “During the war years, people obtained first aid licenses and began treating patients without formal training. Once conditions stabilized, they continued their high-paying jobs, which sometimes interfered with the work of qualified professionals” (P04, university lecturer).

Participants proposed several practical solutions. Many called for the development of a comprehensive HR development plan encompassing recruitment, training, and retention. A policymaker at the MOPH recommended, “The Ministry should develop a holistic strategic plan for HR management that includes both financial and non-financial incentives to prevent the migration of skilled workers—for example, increasing salaries, providing benefits, and creating opportunities for career advancement” (P38, policymaker, MOPH). Others emphasized the need for accurate population data to inform HR planning. A WHO officer explained, “Before assessing HR needs, we must have reliable statistics about the country’s population, which we currently lack. Workforce planning should be based on both national and provincial population data” (P37, WHO officer). Additional suggestions included policies promoting equitable distribution of health workers across provinces—such as requiring service in rural areas for at least two years, improving living conditions, or providing salary incentives—and the appointment of experienced managers with strong health program expertise.

HR recruitment

Participants described both structural strengths and persistent challenges within the recruitment of the health workforce for communicable disease (CD) control in Afghanistan. Recruitment through transparent online platforms—particularly the Agency Coordinating Body for Afghan Relief and Development (ACBAR) website—was frequently cited as a positive practice, as was the merit-based selection of most health workers and the adherence to WHO’s guidelines in the recruitment of community health workers (CHWs).

Despite these mechanisms, a shortage of qualified health workers—especially female professionals—was identified as a critical constraint. Several participants emphasized the scarcity of CD specialists in remote regions, alongside the issue of job insecurity. As a policymaker from the CDC Directorate explained, “Many health workers are contracted through international organizations. When these organizations stop operating, their employees lose their jobs. Later, when they apply to other organizations, their applications are often rejected due to limited vacancies” (P35, policymaker, CDC).

Opportunities were noted in the form of increased vacancies within the health sector following the emigration of professionals after the recent political transition. A manager from the MOPH remarked, “After the change in government, many health professionals left the country, creating job opportunities for those seeking work in the health sector” (P42, manager, MOPH).

However, participants also identified systemic threats such as nepotism, favoritism, and recruitment influenced by language or political affiliation. Additionally, financial constraints and poor living conditions in remote areas were perceived as major deterrents to attracting and retaining staff. Participants proposed addressing workforce shortages by increasing the national budget for health sector recruitment, hiring retirees part-time, and offering overtime work for existing employees. Correcting gender imbalance and ensuring merit-based recruitment were also seen as priorities. A policymaker in the CDC Directorate recommended, “All institutions providing health services should ensure that recruitment is handled through the government to provide job security, so that staff cannot be dismissed whenever implementing partners change” (P35, policymaker, CDC).

HR education and training

Education and training emerged as a critical determinant of workforce capacity for CD management. Participants highlighted the availability of qualified specialists, nurses, and midwives; the inclusion of an infectious diseases course tailored to the Afghan context within the medical curriculum; and the existence of in-service and refresher training programs as key strengths.

Nonetheless, several major weaknesses were identified, including a shortage of CD super-specialists, outdated knowledge among practitioners, and high illiteracy rates among CHWs. A WHO officer observed, “There are around 30,000 volunteer CHWs, most of whom are illiterate. They don’t know medical terminology or the names of medicines” (P01, WHO officer). Another WHO officer added, “CHW programs face many challenges—unclear roles, inadequate training, poor supervision, and weak linkages with both health systems and communities” (P37, WHO officer). Participants also lamented the cessation of international training scholarships after the regime change, the limited number of domestic training programs, and declining educational quality in private medical universities. As a lecturer explained, “After the change in government, scholarships for medical students and doctors from international universities stopped” (P02, lecturer). Another lecturer noted, “In remote clinics, health workers often have limited knowledge about CDs, leading to underdiagnosis and underreporting” (P04, lecturer). A former university chancellor further added, “Private medical universities admit students without proper entrance exams, so many graduates lack the fundamental understanding of medical science. Overcrowded classrooms and hospitals have further reduced educational quality” (P05, former chancellor).

Donor support for training and the growing youth interest in medical careers were identified as important opportunities. A lecturer noted, “Most students in the national entrance exam choose medical universities and institutes because they see medicine as a stable and respected career” (P10, lecturer).

However, the ban on women’s education, restrictive cultural norms, and donor funding cuts were identified as significant threats. To address these challenges, participants suggested advocating for female education, updating curricula, and expanding on-the-job training across all hospitals. Other recommendations included improving the regulation of private universities, using technologies such as telemedicine to reach underserved areas, strengthening partnerships with international medical schools, and enhancing CHW programs by providing structured training and gradually replacing untrained or illiterate workers with competent professionals.

HR relations

Effective interpersonal and professional relationships were viewed as essential for CD management. Participants described generally positive communication among health staff, managers, and patients, and a friendly working environment in most health centers. A manager from the Public Health Institute noted, “Since Afghanistan is a multilingual country, there is no language barrier in most health facilities, as most health workers are recruited from their own hometowns” (P11, manager, Public Health Institute).

Nevertheless, weak conflict management mechanisms and staff burnout due to heavy workloads were perceived as significant challenges. A service provider explained, “Poor communication among healthcare professionals often leads to medical errors. Because of excessive workloads, doctors sometimes write unclear prescriptions, causing pharmacists to administer the wrong medications” (P48, service provider).

Participants saw opportunities in the widespread use of mobile phones and internet technologies, which could facilitate patient–provider communication and coordination. However, threats such as the interference of influential individuals, verbal abuse toward healthcare personnel, and gender-based segregation in hospitals were noted to hinder collaboration and increase the risk of medical errors. Participants recommended providing psychological and social support to reduce burnout, as well as establishing effective mechanisms for conflict resolution and professional communication.

HR performance appraisal

Participants reported that the Performance Management Standard Operating Procedures within the MOPH framework provide a structured approach to evaluating staff. Regular attendance monitoring was highlighted as a strength. A manager from the Afghanistan Institute of Public Health observed, “Doctors and health workers are required to be present until four in the afternoon, so we monitor attendance strictly” (P12, manager, Institute of Public Health).

However, the lack of mechanisms to recognize employee potential and low levels of professional commitment were cited as weaknesses. A senior MOPH manager explained, “Because government salaries and incentives are low, many employees work in two or three places to earn extra income. This negatively affects service quality, and patients don’t receive the care they need” (P42, manager, MOPH).

While some participants noted that strict government supervision had increased attendance, unequal pay between frontline CD health workers and administrative managers was described as a demotivating factor. To improve performance management, participants recommended installing digital attendance systems, implementing fair salary structures, and recognizing the contributions of frontline staff through transparent appraisal mechanisms.

HR compensation

Compensation emerged as a cross-cutting factor influencing motivation and workforce retention. Participants mentioned that salaries and benefits for professors, lecturers, and health professionals in NGOs and private hospitals were generally adequate, contributing to workforce stability in those settings.

In contrast, low salaries in government health institutions and lack of job security were viewed as major weaknesses, leading to low morale and reduced professional loyalty. Participants identified the strong social respect accorded to doctors and health workers in Afghan society as an opportunity that could be leveraged for professional motivation and advocacy.

However, the absence of a dedicated medical court was identified as a pressing threat. A pediatrician explained, “When a patient dies, the relatives often file a case against the doctor, forcing the physician to compensate the family even when there was no medical error” (P26, pediatrician).

To improve HR compensation, participants proposed increasing the salaries of frontline workers combating CDs, introducing risk allowances for technical staff, and creating a more supportive professional environment through recognition, fair pay, and legal protection mechanisms for healthcare providers.

Discussion

In this qualitative research, we examined the current state of the health workforce by identifying its strengths, weaknesses, opportunities, and threats related to the management of CDs, along with proposed solutions. The analysis covered six sub-themes: HR planning, recruitment, education and training, employee relations, performance appraisal, and compensation.

The key strengths identified were the established network of CHWs and the recruitment of human resources via online platforms. Major weaknesses included the uneven distribution of health workers, an imbalance between supply and demand, a shortage of qualified top- and mid-level managers, the underrepresentation of female professionals, and low salaries among health personnel. The availability of a competent young health workforce was considered a major opportunity, whereas brain drain, resource limitations, and government restrictions on women’s education emerged as significant threats.

Most experts highlight the presence of CHWs networks as a key strength of primary health care systems. CHWs have been widely deployed to mitigate the shortage of skilled health professionals, particularly in resource-constrained settings [22]. CHW programs have been established across diverse health system contexts globally, spanning low-, middle-, and high-income countries [23]. A study by Barnett et al. demonstrated that CHW programs are associated with improved quality of care, as well as substantial reductions in healthcare utilization and costs [24].

CHWs can be trained more quickly than doctors or nurses, enabling governments to rapidly expand services to meet urgent needs. Although their skills are more limited, CHWs can effectively prevent and treat CDs and other primary health issues [25]. In Afghanistan, however, most CHWs are elderly and illiterate [13]. Experts—including our team—recommend replacing them with literate youth and professional personnel. Unfortunately, many educated individuals and skilled professionals are leaving the country to pursue low-skilled employment opportunities abroad.

Many experts also identify the uneven distribution of the health workforce as a major weakness affecting healthcare systems worldwide. For instance, in Nigeria, rural communities—despite comprising nearly half of the population—have access to only about 12% of physicians and 19% of nurses. To address this disparity, the Nigerian study recommended financial and non-financial incentives, particularly low-cost approaches such as structured recognition and reward schemes, to improve motivation and retention among rural health workers [26]. Consistent with these insights, the present study proposes similar strategies to promote equitable workforce distribution and strengthen human resource management in Afghanistan.

The education and training of health workers significantly influence their distribution and practice locations. Urban-centered medical education often leads to physician concentration in cities, whereas graduates from rural-based schools are more likely to work in underserved areas and choose primary care specialties. Countries like Canada and Brazil have successfully implemented policies to reduce overspecialization and improve geographic distribution. Continuous professional education is also essential, particularly for those in remote areas, to ensure skill development and meet evolving health system needs [27].

In Afghanistan, the issue is particularly acute due to poor living conditions in rural areas. Many remote regions face lack of electricity, impassable roads, limited communication services, inadequate access to quality schools for children, and, most critically, insecurity. To address these challenges, some experts propose policies such as compulsory service programs—similar to those implemented in 70 countries [28]—or compensation and motivation strategies for healthcare workers, as indicated by Solihah (2021) [29]. Another major challenge is the lack of an accurate population count. Current estimates are imprecise, and obtaining accurate population data would enable better planning for equitable healthcare workforce distribution.

The imbalance between supply and demand represents another significant weakness. Despite a substantial number of doctors, nurses, and midwives graduating each year from public and private institutions, the supply remains insufficient. Many graduates work outside their areas of expertise, and government budget constraints hinder effective recruitment. At the same time, support for the health system has declined due to reduced international aid following the political transition. Experts recommend increasing the government budget to hire sufficient human resources, as suggested in a Kenyan study by Nyawira (2022) [30].

Finally, the shortage of female employees within the health system remains a major challenge. Following the political transition from the Islamic Republic to the Islamic Emirate in 2021, new restrictions were imposed on women’s participation in the workforce and access to education. While these measures were officially justified by social and security considerations, they have profoundly undermined women’s rights to work and education—fundamental human rights recognized under international law. The resulting gender imbalance in the health workforce not only violates these rights but also deepens health inequities, particularly in communities where cultural norms restrict women from receiving care from male providers. This has reduced women’s access to essential health services, weakened service delivery, and widened existing disparities in health outcomes. Addressing this issue therefore requires sustained international advocacy and diplomatic engagement, as it encompasses complex intersections between political realities, human rights obligations, and health equity—factors that extend beyond the scope of internal health sector reforms.

Policy implications

This study underscores the need for targeted, equitable, and gender-responsive HR policies to strengthen CD management in Afghanistan. The following policy directions are proposed:

1. Develop a comprehensive national HR strategic plan Policymakers should establish a national framework that ensures equitable distribution of health workers based on accurate population data.

2. Promote equitable workforce distribution Implementing mandatory rural service rotations and introducing both financial and non-financial incentives can help address the urban–rural imbalance in workforce allocation.

3. Enhance gender equity and women’s participation Addressing the shortage of female health professionals is critical. International advocacy and collaboration are needed to remove barriers to women’s education and employment. Short-term measures such as distance education, targeted scholarships, and safe working environments should be prioritized.

4. Strengthen capacity building and professional development Updating medical curricula, expanding continuous training opportunities, and incorporating digital learning tools will improve workforce competence and adaptability.

5. Improve governance and accountability mechanisms Transparent recruitment processes, standardized performance appraisals, and fair compensation structures are essential to enhance motivation, accountability, and retention.

6. Ensure sustained international and financial support Ongoing technical and financial assistance is vital to counter brain drain, reinforce institutional capacity, and ensure long-term health system resilience.

Study limitations

A key limitation of this study relates to the professional background of many policymakers and program managers in the Afghan healthcare sector. Although most participants held medical degrees and brought valuable clinical experience, few had formal training in public health or health management. This lack of specialized expertise may have influenced their perspectives on health system issues and constrained their ability to address broader management challenges, particularly those concerning CDs.

Another important limitation was the gender imbalance among participants. Of the 49 individuals involved, only two were women, reflecting the broader shortage of female health professionals in Afghanistan—an outcome of governmental restrictions on women’s employment. This gender imbalance may have limited the diversity of perspectives, particularly concerning challenges faced by female healthcare workers and the gendered implications of health management in Afghanistan.

Conclusion

The health system in Afghanistan is facing a critical shortage of HR, particularly in the management of CDs. Effective management of CDs requires a knowledgeable, accessible, and dedicated workforce. To address this issue, the following steps are essential: 1. Planning by assessing supply and demand: Evaluating the current availability of skilled workers and identifying areas of need. 2. Merit-Based Recruitment: Hiring qualified individuals based on their competencies and experience. 3. Capacity Building: Providing training in updated medical practices to enhance the skills of existing staff and refreshing their knowledge. 4. Retention Strategies: Implementing practices to support and motivate healthcare workers, such as offering incentives, improving living conditions, promoting career advancement, and recognizing their contributions to health services.

By focusing on these strategies, the challenges related to human resources for managing CDs in Afghanistan can be effectively addressed.

Abbreviations

ACBAR

Agency Coordinating Body for Afghan Relief and Development

CCHF

Crimean Congo hemorrhagic fever

CDC

Center for Disease Control and Prevention

CDs

Communicable diseases

CHWs

Community health workers

DOTs

Directly observed treatment short course

HDI

Human Development Index

HR

Human resource

HRM

Human resource management

IP

Interpretative phenomenology

LMIC

Low and lower-middle income countries

MOF

Ministry of Finance

MOPH

Ministry of Public Health

NGOs

Non-Government Organizations

SWOT

Strength, weakness, opportunity and threat

TB

Tuberculosis

WHO

World Health Organization

Author contributions

EH and AMM designed the study, developed the interview guide, collected and analyzed the data, and drafted the manuscript. AMM also contributed to manuscript editing. Both authors have read and approved the final version of the manuscript.

Funding

This research was funded by the Tehran University of Medical Science.

Data availability

The datasets used in this study can be obtained from the corresponding authors upon request.

Declarations

Ethics approval and consent to participate

Ethics approval for this study was granted by Tehran University of Medical Sciences under the code IR.TUMS.SPH.REC.1400.262.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.