Table 1.

Afghanistan case report

Theme	Findings
Background	In 1978, the former Soviet Union military invaded Afghanistan, leading to chronic conflict, insecurity and instability in Afghanistan. The communist regime remained in power until 1992, and during the 13 years of its ruling, it contributed little to the welfare of the people. After taking power in 1992, a coalition of Mujahedeen factions brought Afghanistan into a new time of conflict, civil war and inter-Mujahedeen fighting. The Taliban ruled the country from 1996 to November 2001. The Taliban showed little interest in the health sector [73]. In December 2001, the Taliban regime collapsed and a new democratic government was established. In 2002, the level of health services was shocking. Lack of a policy framework, inequalities in health service provision across the country, low capacity of public and private sectors, differences in the quality of the services, the absence of infrastructure, lack of coordination and shortage of health human resources were some of the main challenges [74].
Institutional capacity	After the establishment of the new government, the institutional capacity of the Ministry of Public Health (MoPH) at the central level has been strengthened with the provision of training programmes and the hiring of a number of local consultants. Regulatory documents and guidelines to support the hiring and management of HR have been put in place in collaboration with the Civil Service Commission. Despite these efforts at the central level, at the decentralized level, the state capacity to provide services is still weak. Scholars working on public administration and civil service (beyond the health sector) in Afghanistan have highlighted the gap between the formal and informal institutions. The limited reach that the de jure state has in the provinces leaves room for a de facto authority structure of warlords, with commanders filling in the state functions and weakening its legitimacy [75].
Intersectoral coordination	Intersectoral collaboration has been reinforced by increasing coordination and dividing tasks between different institutions within the public administration so that the Civil Service Commission hires top grade officers (general directors and directors), while the MoPH is responsible for hiring all other officers. However, the institutional capacity is not at optimal level. Moreover, the financial capacity of the government to pay its officials remains limited. Most of the staff in key positions of the MoPH, while officially employed by the government, receive a salary or a salary supplementation from external organizations and development projects. Although work has been done to attempt to align and harmonize pay, disparities in remuneration still exist, which are a cause of demotivation for health workers (HWs) [76,77].
Adequacy and coverage of HRH	In contrast to other services provided by the public administration, health service delivery at the decentralized level has been contracted out to NGOs [60]. In terms of the presence of funded, effective and responsive HRH, NGOs hire health workers directly. In 2003, the MoPH developed a national salary policy to standardize HWs’ remuneration across the country and compensate particularly female HWs for assuming posts in rural and underserved areas [78]. The remoter the HWs, the higher the salaries they receive. However, due to the lack of health care workers, especially of higher cadres, in rural areas and the high security risks, disparity in health provision and inadequate HRH compared to the population needs is noticeable. The most recent HRH Strategy points to gender imbalances as well as disparities in urban/rural distribution of HWs—for example, there are 16.7 public health workers per 10 000 (including unqualified support staff) in rural areas, compared with 36 per 10 000 in urban areas [76]. These issues may contribute to the problems that characterize the health system and the weak public health care provision. Evidence at household level suggests limited utilization of (NGO-provided) public health services, perceptions that these offer inferior quality and a preference for private providers [79].
Integration fo HRH	While official regulations do not allow for discrimination in provision of employment, in practice, it is difficult to ensure a non-discriminatory environment and transparency of hiring practices. Political and tribal pressures exist, and favouritism and nepotism are common when hiring new staff, particularly in key positions, also at the central level [77]. It has been noted that the preferential support of donors for discrete health programmes and the establishment of parallel management systems outside the MoPH, rather than broader institutional support to the MoPH, including to anti-corruption and transparency programmes, may hamper the progress made on these issues, which are essential for the improvement of the public health sector [77].
	Reinforcement of the public civil service for the provision of health care services seems to be following two tracks. At the central level, the presence of a cadre of professionals that are well-trained and relatively well-paid (with external salary supplements) seems to be playing a role in contributing to the state-building process (despite some persistent difficulties). At the local/decentralized level, however, improvements in the availability, distribution and adequacy of HRH seems to be hampered by insecurity so that the strengthening of HRH (and health service provision) appears to rest on state-building rather than contributing to it.