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Today NPR reports on the “stunning progress” made on health in Afghanistan. A USAID-funded survey conducted in 2010 –excluding parts of the high conflict South Zone- finds that mortality and fertility have dropped and coverage of essential services increased dramatically. Male adult mortality has been halved in roughly a decade. Average life expectancy for girls and boys is now 64 years, versus 45 years old in 2001. As USAID’s Alex Thier puts it in the interview, this is “the greatest single increase anywhere on the planet in the last decade.”

Since USAID is the largest funder of health services in Afghanistan and the US is a leader in the Afghan peace-building effort, this looks like very good news. Both the survey and other impact evaluations show US spending on health has made a difference for people’s lives in Afghanistan.

But 75% of spending on health is funded by Afghans themselves, out of pocket (see here).  Alex Thier sees this as a “great sign”, as an indication that Afghans are “very invested in their own health care. That has made the health care system in Afghanistan sustainable.”

Briefing failure!  High levels of out-of-pocket (OOP) spending actually signal poor health financing strategy, with high risks of further impoverishing the extremely poor households that live in Afghanistan. Worse still, unless you have a strong regulatory framework of health savings accounts or other schemes that would make no sense in a low-income country like Afghanistan, high OOP is not a good plan for sustainability of USAID investments. When we use the euphemism of transitioning to more sustainable “country ownership”, we are not talking about OOP, we are talking about public spending on health which remains a low $2.50 per capita, an amount not up to buying even a basic set of immunizations.

If the US wants to sustain the “stunning progress”, it will have to work to increase public spending on health.