The availability of essential medicines in public health facilities in Afghanistan: navigating socio-political and geographical challenges.

During the past two decades, the Afghan government, along with international community, has developed a system aimed at improving access to essential health services under Afghanistan's challenging socio-political and geographical circumstances. In 31 provinces, non-state actors competed for fixed-term contracts to implement a predefined package of health services. In three provinces, the government organised the provision of health services. An independent third party monitored service provision, including access to medicines. This study examines the availability of essential medicines in Afghanistan's public health facilities and how this is shaped by socio-political challenges, geographical barriers, and the organisation of the health system. Between March and July 2021, enumerators collected data at 885 health facilities across Afghanistan. For our analysis, we combined data about medicine availability and the functioning of the health system with publicly available information about geographical and socio-political factors, including security incidents. Using regression analysis, we identified facility, district, and province-level factors related to medicines availability in public health facilities. On average, 70% of 31 selected essential medicines were available in 2021. The availability of medicines varies significantly between provinces and was considerably higher in those where services were contracted out to non-state actors (n=34; 91%) compared to provinces where service provision was organised by the government (n=3; 9%). The most important drivers of variation in medicine availability included geographical barriers, securing and allocating funds on the provincial level, and organising and sustaining physical capacity on the facility level. Insecurity was not a key factor driving variation in medicine availability. Despite the socio-political challenges in 2021, the availability of essential medicines in public health facilities was relatively high. The results suggest that decentralized procurement of medicines by non-state actors and timely payment of funds contribute to medicines availability. Strategies to improve medicines availability should target hard-to-reach areas and lower-level facilities.