Abstract
During the past two decades, the Afghan government, along with the international community, has developed a system aimed at improving access to essential healthcare services under Afghanistan's challenging sociopolitical and geographical circumstances. In 31 provinces, nonstate actors competed for fixed-term contracts to implement a predefined package of healthcare services. In three provinces, the government organized the provision of healthcare services. An independent third party monitored service provision, including access to medicines. This study examines the availability of essential medicines in Afghanistan's public healthcare facilities and how this is shaped by sociopolitical challenges, geographical barriers, and the organization of the healthcare system. Between March and July 2021, enumerators collected data at 885 healthcare facilities across Afghanistan. For our analysis, we combined data on medicine availability and the functioning of the health system with publicly available information about geographical and sociopolitical factors, including security incidents. Using regression analysis, we identified facility-, district-, and provincial-level factors related to medicine availability in public healthcare facilities. On average, 70% of 31 selected essential medicines were available in 2021. The availability of medicines varied significantly between provinces and was considerably higher in those where services were contracted out to nonstate actors (n = 31; 91%) compared to provinces where service provision was organized by the government (n = 3; 9%). The most important drivers of variation in medicine availability included geographical barriers, securing and allocating funds at the provincial level, and organizing and sustaining physical capacity at the facility level. Insecurity was not a key factor driving variation in medicine availability. Despite the sociopolitical challenges in 2021, the availability of essential medicines in public healthcare facilities was relatively high. The results suggest that decentralized procurement of medicines by nonstate actors and timely payment of funds contribute to medicine availability. Strategies to improve medicine availability should target hard-to-reach areas and lower-level facilities.