Barriers and Strategies for Health Policy Implementation in Afghanistan: Presenting an Indigenous Model
Keywords:
Policy implementation, health system, Afghanistan, health governance, content analysisAbstract
This study aimed to identify the barriers and strategies for implementing health policy in Afghanistan and to present an indigenous model aligned with the country’s political, institutional, economic, and socio-cultural conditions. This qualitative study was conducted using thematic analysis based on Braun and Clarke’s six-step framework. The participants consisted of 16 health policymakers, executive managers, physicians, nurses, frontline health workers, and academic experts in Afghanistan who were selected through purposive sampling. Data were collected through semi-structured interviews and continued until theoretical saturation was reached. All interviews were recorded, transcribed verbatim, and repeatedly reviewed. Data analysis was performed through open, axial, and selective coding using MAXQDA 2020 software. The analysis resulted in the extraction of 512 initial codes, which were organized into three main axial categories: financial resources, budgeting, and allocation efficiency; infrastructure, technology, and implementation readiness; and participation, accountability, transparency, and public trust. The selective code, entitled “reproduction of inefficiency in health policy implementation,” indicated that Afghanistan’s health system is trapped in a defective cycle that begins with financial dependence on external sources, continues through short-term and non-analytical budgeting, is intensified by weak infrastructure and technological capacity, and ultimately leads to implementation failure through insufficient transparency, accountability, and public trust. The proposed indigenous model suggests that improving health policy implementation in Afghanistan requires evidence-based budgeting, strengthened technical and information infrastructure, human resource capacity building, institutionalized community participation, enhanced transparency and accountability, and greater managerial stability. This model can serve as a practical framework for narrowing the gap between health policy formulation and implementation and for improving health governance in Afghanistan.
Downloads
References
Agustin, L., & Solikin, M. Y. (2021). Analysis of SMEs Credit Restructuring Policy in Economic Recovery during the COVID-19 Pandemic. Jurnal Muara Ilmu Ekonomi Dan Bisnis, 5(2), 405-416. https://doi.org/10.24912/jmieb.v5i2.13087
Ahmadi, A. (2023). Identifying and Ranking Barriers to the Implementation of Public Policies in Afghanistan's Education System [Master's thesis in Public Administration, Public Policy-Making, University of Tehran, Regional Campuses, Alborz Campus].
Ahmadi, E., & Aftabi, P. (2022). Examining the Position of Social Participation in the Process of Conservation and Management Policy-Making for World Heritage Cities. Bagh-e Nazar, 19(115), 69-80.
Aiyede, E. R. (2022). Governance and Politics of Public Policy in Africa. In Public Policy and Research in Africa (pp. 87-121). Springer International Publishing. https://doi.org/10.1007/978-3-030-99724-3_5
Alvani, S. M., & Sharifzadeh, F. (2024). The Process of Public Policy-Making. Allameh Tabataba'i University Press.
Arif, S., Rezaie, K. F., Madadi, S., & Mousavi, S. H. (2023). Afghanistan's Healthcare under Taliban: What Are the Challenges? Medicine, Conflict and Survival, 39(1), 93-99. https://doi.org/10.1080/13623699.2023.2170576
Basij-Rasikh, M., Dickey, E. S., & Sharkey, A. (2024). Primary Healthcare System and Provider Responses to the Taliban Takeover in Afghanistan. BMJ Global Health, 9(2). https://doi.org/10.1136/bmjgh-2023-013760
Bogale, B., Scambler, S., Mohd Khairuddin, A. N., & Gallagher, J. E. (2024). Health System Strengthening in Fragile and Conflict-Affected States: A Review of Systematic Reviews. PLoS One, 19(6), e0305234. https://doi.org/10.1371/journal.pone.0305234
Braun, V., & Clarke, V. (2024). Thematic Analysis: A Practical Guide (E. Ebrahimi, Trans.). Academic Center for Education, Culture and Research Publications.
Buzogany, A., & Pulzl, H. (2024). Top-Down and Bottom-Up Implementation. In Handbook of Public Policy Implementation (pp. 116-126). Edward Elgar Publishing. https://doi.org/10.4337/9781800885905.00016
Chatarchi, N. (2022). Identifying Inhibiting Factors in the Implementation of Human Resource Training and Development Policies in the Public Sector: A Study of the Social Security Organization [Master's thesis in Public Administration, Decision-Making and Public Policy-Making, University of Tehran, Faculty of Management].
Chen, M., Ji, T., Wedlock, P. T., Bwire, V., Nyanchama, E., Mbelesia, J. A., & Alonge, O. (2026). Implementation Pathways of a Health Services Delivery Redesign Model to Improve Maternal and Newborn Outcomes in Kenya. BMJ Global Health, 11(1). https://doi.org/10.1136/bmjgh-2024-018240
Doshmangir, L., Sanadghol, A., Kakemam, E., & Majdzadeh, R. (2025). The Involvement of Non-Governmental Organisations in Achieving Health System Goals Based on the WHO Six Building Blocks: A Scoping Review on Global Evidence. PLoS One, 20(1), e0315592. https://doi.org/10.1371/journal.pone.0315592
Esmaeili Seraji, M. J., Karam, S., & Enayati, T. (2023). Designing a Model for Implementing Health Policy in the Administrative System with Emphasis on Conflict of Interest Management. Razi Journal of Medical Sciences, 30(6), 248-256.
Harrison, M. I., & Shortell, S. M. (2021). Multi-Level Analysis of the Learning Health System: Integrating Contributions from Research on Organizations and Implementation. Learning Health Systems, 5(2), e10226. https://doi.org/10.1002/lrh2.10226
Head, B. W. (2023). Wicked Problems in Public Policy. In Encyclopedia of Public Policy (pp. 1-8). Springer International Publishing. https://doi.org/10.1007/978-3-030-90434-0_43-1
Hodoudi, A., Asadi Davoudabadi, M. H., & Roshanaei, A. (2022). Sociology of Social Issues in Iran in the Field of Health. Journal of Mashhad University of Medical Sciences Faculty of Medicine, 65(1), 521-544.
Howlett, M. (2023). Designing Public Policies: Principles and Instruments. Routledge. https://doi.org/10.4324/9781003343431
Ibrahimi, S., Yeo, S., Yusuf, K., Akrami, Z., & Roy, K. (2025). Factors Hindering Access and Utilization of Maternal Healthcare in Afghanistan under the Taliban Regime: A Qualitative Study with Recommended Solutions. Healthcare, 13(9), 1006. https://doi.org/10.3390/healthcare13091006
Kalaherian, R., & Khastar, H. (2011). Decision-Making and Policy-Making in the Public Sector. Sanjesh va Danesh.
Kiani, M. A. (2025). Designing a Semi-Centralized Governance Model for the Health System in Iran [Doctoral dissertation in Geography, Political Geography, University of Tehran, Faculty of Geography].
Lamberti-Castronuovo, A., Valente, M., Bocchini, F., Trentin, M., Paschetto, M., Bahdori, G. A., & Ragazzoni, L. (2025). Exploring Barriers to Access to Care Following the 2021 Socio-Political Changes in Afghanistan: A Qualitative Study. Conflict and Health, 18(1), 36. https://doi.org/10.1186/s13031-024-00595-4
Maisarah, G., & Yusran, R. (2025). Exploring the Key Factors in the Implementation of the GERMAS Policy: A Public Management Perspective Using the Mazmanian and Sabatier Framework. Journal of Educational Management Research, 4(4), 1870-1879. https://doi.org/10.61987/jemr.v4i4.1144
Mehrara, A., & Motavalli, A. (2025). Challenges and Problems of Public Policy-Making Issues. New Research Approaches in Management and Accounting, 9(32), 31-47.
Miri Nejad, E. (2024). Drivers of Effective Implementation of the Family Physician Plan and Referral System Policy in Sistan and Baluchestan Province [Master's thesis in Public Administration, Decision-Making and Public Policy-Making, University of Sistan and Baluchestan, Faculty of Management and Economics].
Nagra, G. M., Nawaz, A., Imran, M., Javed, M., & Mustafa, G. (2024). People, Politics, and Society: A Historical Analysis of Afghanistan. Remittances Review, 9(2), 539-556.
Nematian Saghi, H. (2025). Pathology of the Implementation of Nursing Service Tariff-Setting Policy in Human Resource Management [Master's thesis in Public Administration, Human Resource Development, Payame Noor University of South Khorasan Province, Birjand Payame Noor Center].
Paterson, A., Palmer, J., & Sondorp, E. (2025). Health System Governance Cooperation with Unrecognised Health Authorities: A Political Economy Analysis in Afghanistan and Northwest Syria. Conflict and Health, 19(1), 30. https://doi.org/10.1186/s13031-025-00669-x
Percival, V., Thoms, O. T., Oppenheim, B., Rowlands, D., Chisadza, C., Fewer, S., & Friberg, P. (2023). The Lancet Commission on Peaceful Societies through Health Equity and Gender Equality. The lancet, 402(10413), 1661-1722. https://doi.org/10.1016/S0140-6736(23)01348-X
Petridou, E., & Mintrom, M. (2021). A Research Agenda for the Study of Policy Entrepreneurs. Policy Studies Journal, 49(4), 943-967. https://doi.org/10.1111/psj.12405
Sari, A. R. (2023). The Impact of Good Governance on the Quality of Public Management Decision Making. Journal of Contemporary Administration and Management (ADMAN), 1(2), 39-46. https://doi.org/10.61100/adman.v1i2.21
Shahid, M., Omerzad, M. Z., Hashemi, S. S., Hamidi, N., Sultany, H. S., Sultani, M. Y., & Farhikhta, F. (2026). Cancer Screening in Afghanistan: A Narrative Review of Feasibility, Barriers, and Evidence-Based Strategies for Low-Resource Settings. Cureus, 18(1). https://doi.org/10.7759/cureus.101346
Singh, B. (2023). Reimagining Human Rights: Harnessing the Power of Law for Global Health and Sustainable Development Goals. Human Rights in the Global South, 2(2), 93-105. https://doi.org/10.56784/hrgs.v2i2.65
Touchton, M., Arreola-Ornelas, H., Arizmendi-Barrera, K. A., Enciso, V. V., & Knaul, F. M. (2026). Drivers and Barriers for the Implementation of Value-Based Healthcare in Latin America: A Cross-Country Qualitative Policy Analysis. The Lancet Regional Health - Americas, 53. https://doi.org/10.1016/j.lana.2025.101307
Ugwu, C. N., Ugwu, O. P. C., Alum, E. U., Eze, V. H. U., Basajja, M., Ugwu, J. N., & Uti, D. E. (2025). Sustainable Development Goals (SDGs) and Resilient Healthcare Systems: Addressing Medicine and Public Health Challenges in Conflict Zones. Medicine, 104(7), e41535. https://doi.org/10.1097/MD.0000000000041535
Ye, J., He, L., & Beestrum, M. (2023). Implications for Implementation and Adoption of Telehealth in Developing Countries: A Systematic Review of China's Practices and Experiences. NPJ Digital Medicine, 6(1), 174. https://doi.org/10.1038/s41746-023-00908-6
Downloads
Published
Submitted
Revised
Accepted
Issue
Section
License
Copyright (c) 2025 Mutiullah Sharq (Author); Vahid Araei; Mohammad Reza Rabiee Mandejin, Hasan Givarian (Author)
This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.
