Taking the long view:
What can we learn about health system resilience in fragile contexts from Afghanistan (1989-2024)?


Partners: Queen Margaret University, UK and KIT Institute, Netherlands [opens new tab]


Background to the study

In the past 35 years Afghanistan has experienced multiple shocks, with attempts by the international community to alleviate suffering and rebuild the health system using heavy reliance on non-state actors. This case study aims to analyse investments and developments over this long time period (1989-2024), considering in particular the relative role of the non-state sector and how its engagement has shaped both its actors and progress within the Afghanistan system.


Research objectives

The case study is exploratory but seeks to broadly explore the hypothesis that the existence (in 2001) of a vibrant, capacitated and partly local NGO community has been the backbone of the success of a contracting approach and remaining resilience of the health system.

In order to do this, there are several key areas that are important to keep in view. The data collection will maintain a focus on the following:

  • Taking a view across the whole 30+ years to allow an understanding both of what was in place in 2001 and also what resilience the system has been able to show since 2021
  • Maintaining a focus on the whole system (geographically and levels of care), understanding whether and how investments have translated into a strengthened health system
  • The experience and choices made during the development of the Basic Package of Health Services for Afghanistan, including its performance-based financing phase and key requirements for these to be successful
  • The ‘foreign gaze’ and how that impacts upon the way the Afghan case is presented and interpreted
  • The Ministry of Health (as an institution within a project, as a key driver of future resilience); other key individuals and institutions (external?) and the role that they have played

The case study will pay particular attention to less well articulated viewpoints such as those of the local NGOs and concepts of resilience, its meaning within the Afghanistan experience and what we can learn in relation to what capacities were built or not (and why).


Image: A doctor listens to a patient in a community health clinic in Danishmand, Afghanistan in 2010. DFID via Flickr [opens new tab] CC BY-NC-ND 2.0 DEED


"ReBUILD for Resilience brings together partners to share experiences, to discuss our contexts, and to create an appropriate model that helps build resilience in health systems across the country and beyond"

Sushil Baral, HERD International