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Institutionalization of National Health Accounts in Afghanistan


As part of  United States Agency for International Development's (USAID) Health Systems 20/20 project, Deloitte assisted the Ministry of Public Health (MoPH) in Afghanistan in producing its first series of National Health Accounts (NHA). Findings have highlighted the critical need to increase government expenditure on health care and reduce the household financial burden. Deloitte is also supporting the institutionalization of the NHA process in Afghanistan in order to motivate greater use of and demand for NHA as not only a tool for budgeting and tracking, but also to inform national health policy.

The Challenge

Afghanistan's donor-dependent public health system has fueled concerns about the long-term sustainability of existing health services. Poor national oversight on health care spending makes it challenging to determine how to allocate resources to increase the utilization of health services and improve overall health outcomes. Prevailing security concerns, isolation, and restrictions on the movement of staff inhibit regular collection and sharing of the necessary data. In addition, the contracting of multiple non-governmental organizations (NGOs) --with varying reporting standards --to deliver health services in the country further complicates the proper tracking of health expenditures.

How We Helped

The project team worked with Afghan counterparts to produce estimates of health expenditures that could be used to assess efficiency in the use of resources allocated to the health sector. In addition, the team is supporting the institutionalization of the NHA process so that health sector policies can continue to be informed by real data on where gaps in financing persist.

To conduct the first round of NHA estimates, Deloitte:

  • Trained Afghan nationals, based at the MoPH who form the core of the country’s NHA technical team
  • Established a multi-stakeholder NHA Steering Committee to provide guidance and oversight on NHA activities
  • Institutionalized collection of NHA data, through the inclusion of household out-of-pocket health expenditure questions in the biennial Afghanistan National Risk and Vulnerability Assessment
  • Modified the hospital management information system to capture hospital costing information in addition to utilization data
  • Finalized the development of a software solution which can allow NGOs to import their data into a common system and output it into the desired donor reporting format

To institutionalize the process, Deloitte is working in collaboration with the MoPH to:

  • Develop a stronger governance structure through strengthening relationships and encouraging collective participation from members of civil society organizations, the private sector, and other domestic institutions who play a significant role in NHA reporting
  • Improve data collection and management processes by coordinating with other ministerial agencies on interoperability of databases, thereby enhancing access to data
  • Devote more human and financial resources to NHA work by training other staff members to lead this exercise
  • Produce an NHA manual with a glossary of terms, data sources used, collection and estimation methods, and other information in order to improve knowledge retention and ease knowledge transfer
  • Encourage the use and dissemination of NHA data through widespread publication, organizing high level meetings, and holding regular stakeholder forums


Afghanistan released the results of its NHA exercise at an inaugural event welcoming close to 100 attendees, including the Minister of Public Health, USAID Deputy Mission Director, representatives from the donor community, hospital directors, and academia.

NHA estimates revealed that Afghanistan spends over US$1 billion (or close to ten percent of GDP) on health care with almost 60 percent directed toward curative services. However, over three-quarters of this spending are done by households with the government’s share at only six percent 1. Deloitte is currently expanding support to the MoPH in line with the policy implications of the exercise, namely in the areas of capacity building, public revenue generation, and financial risk protection.

1 Government of the Islamic Republic of Afghanistan Ministry of Public Health (Forthcoming). National Health Accounts Afghanistan 2008-2009. Kabul, Afghanistan.

Deloitte’s work in Afghanistan under Health Systems 20/20 is carried out under a subcontract with Abt Associates Inc., prime contractor for the Health Systems 20/20 cooperative agreement. Health Systems 20/20 is funded through the generous support of the American people through the U.S. Agency for International Development (USAID). The project helps USAID-supported countries address health system barriers to the use of life-saving priority health services. In the process, the project works to strengthen health systems through integrated approaches to improving financing, governance, and operations, and building sustainable capacity of local institutions.

As used in this document, ‘Deloitte’ means Deloitte Consulting LLP, a subsidiary of Deloitte LLP. Please see for a detailed description of the legal structure of Deloitte LLP and its subsidiaries. Certain services may not be available to attest clients under the rules and regulations of public accounting.

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