Local Governance and Urban Health in Afghanistan: Progress, Challenges, and Future Directions

Background: Afghanistan's health system has undergone substantial transformations over the past two decades, enabled by extensive donor investment and a vertically structured national service delivery framework. While improvements in access, health indicators, and community-based models are well documented, recent shifts in governance and funding have imperiled these gains. This paper examines the role of local governance and urban management in shaping health sector performance, with particular attention to post-۲۰۲۱ developments and decentralization constraints. Methods: We analyzed national health policy documents, survey data, peer-reviewed literature, and grey sources to map historical and contemporary governance structures in Afghanistan's health sector. We focus on health outcomes, financing, service delivery models, and municipal capacity, incorporating updated data from ۲۰۲۳–۲۰۲۵ where available. Results: Maternal mortality declined from ~۱,۶۰۰ per ۱۰۰,۰۰۰ live births in ۲۰۰۰ to ۵۲۱ in ۲۰۲۳, but rose to ~۶۲۰ in ۲۰۲۵ amid funding cuts and service closures. While under-five mortality dropped significantly, service coverage has deteriorated since ۲۰۲۱. Health spending peaked at ۲۲% of GDP in ۲۰۲۱, driven by crisis-level aid, yet domestic financing fell to ۰.۸% of total health expenditure in ۲۰۲۲. Community health workers (CHWs) remain pivotal, covering ۶۰-۷۰% of communities. However, municipal and provincial authorities retain minimal authority over health services, limiting decentralized innovation and accountability. Conclusion: Afghanistan's recentralized health governance model has delivered gains but now faces acute risks. Revitalizing health outcomes requires reimagining local governance capacity, sustaining frontline delivery mechanisms, and safeguarding equity in service access amid systemic shocks.

کلیدواژه ها:

Afghanistan ، local governance ، urban health ، decentralization ، health system resilience