Assessing the health workforce in Afghanistan: a situational analysis into the country's capacity for Universal health coverage.

Background: Universal health coverage (UHC) is a key component of Afghanistan's health plan, but the country faces challenges due to decades of conflict and instability. Concurrently, healthcare successes have been achieved despite significant shortages in the health workforce. A fit-for-purpose health workforce is crucial for achieving UHC, and requires decision-making by policy-makers driven by sufficient evidence. This study presents a comprehensive situational analysis of Afghanistan's health workforce in 2023, focusing on distribution by geography, gender, facility type, as well as trends in health worker production.

Methods: A multi-stage assessment of the active health workforce was conducted through a national census-style count using active registries and facility-level verification through sampled facilities visits. Health worker production was estimated through an analysis of enrollment and graduation figures from public and private institutions from 2019 to 2023.

Findings: We estimated 63,632 health workers in Afghanistan in 2023, with 73% in the public sector and 27% in the private sector. Key health workers (physicians, nurses and midwives) total 10.3 per 10,000 population, falling significantly short of the aspirational UHC threshold (44.5 key health workers per 10,000). Substantial geographic disparity exists between provinces, with remote provinces reporting far fewer key health workers compared to the national average and Kabul representing approximately 50% of the country's specialized physicians. Significant gender imbalances exist as only 18% of specialized physicians and 29% of nurses are female. Health workforce production is largely dependent on the private sector, and has declined for certain cadres due to restrictions on female education, which are increasing in severity. Majority female cadres, such as Obstetrics/Gynecology, are anticipating significant declines in active staff, jeopardizing aspirations of UHC.

Interpretation: Afghanistan faces critical health workforce challenges, including shortages, gender imbalances and unequal geographic distribution. These findings provide essential insights for policymakers to guide human resources policies aimed at achieving UHC.