afg - the public health system in afg

8/4/2019 Afg - The Public Health System in Afg

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Afghanistan Research and Evaluation Unit

Issues Paper Series

The Public Health System inAfghanistan:

Current Issues

Ronald Waldman

Homaira Hanif

May-June 2002


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2002 The Afghanistan Research and Evaluation Unit (AREU). All rights reserved.

This issue paper was prepared by independent consultants with no previous involvement in the activitiesevaluated. The views and opinions expressed in this report do not necessarily reflect the views of the

AREU.


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About the Authors

Ronald Waldman, M.D. M.P.H., is Director of the Programme on Forced Migration and Health, andProfessor of Clinical Public Health at the Mailman School of Public Health of Columbia University.He is a medical epidemiologist and specialist in child health in developing countries, with extensive

experience working in complex emergencies in Somalia, Rwanda, Northern Iraq, Bosnia and Albania.Dr. Waldman began his career as a volunteer with the World Health Organisation (WHO) in Bangladeshduring the smallpox eradication programme. He subsequently worked at the U.S. Centres for DiseaseControl and Prevention for more than 20 years, where he directed technical support activities forthe Combating Childhood Communicable Diseases project and initiated studies of the epidemiologyof refugee health. He was the coordinator of the Task Force on Cholera Control at WHO from 1992-1994 and the technical director of the USAID-funded BASICS Project from 1995-1999. Dr. Waldmanis currently the chairman of the International Health Section of the American Public Health Associationand serves in an advisory capacity to a number of international, non-governmental organisations(NGOs).

Homaira Hanif, M.H.S., an Afghan-American,is a recent graduate of the Johns Hopkins School of

Public Health. The thesis for her Masters in Health Science was on measuringmaternal mortality inAfghanistan. Previously, she worked for Save the Children (US) providing technical and researchsupport to health projects in refugee/IDP camps in Pakistan and Afghanistan.


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About the Afghanistan Research andEvaluation Unit (AREU)

The Afghanistan Research and Evaluation Unit (AREU) is an independent research institution that

conducts and facilitates quality, action-oriented research and analysis to inform policy, improvepractice and increase the impact of humanitarian and development programmes in Afghanistan. Itwas established by the assistance community working in Afghanistan and has a management boardwith representation from donors, UN agencies and NGOs.

Fundamental to AREUs purpose is the belief that its work should make a difference in the lives ofAfghans. AREU is the only humanitarian and development research centre headquartered in Afghanistan.This unique vantage point allows the unit to both produce valuable research and ensure that itsfindings become integrated into the process of change taking place on the ground.

Current funding for the AREU has been provided by the European Commission (EC) and the governmentsof the Netherlands and Switzerland. Funding for this study was provided by the European CommissionHumanitarian Office (ECHO).


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Table of Contents

Executive Summary ....................................................................................... i

I. Introduction....................................................................................... 1

II. The Basic Health Services Package for Afghanistan:

Content ............................................................................................ 4

Maternal and Newborn Health ........................................................ 5

Child Health and Immunisation ....................................................... 7

Public Nutrition ......................................................................... 9

Communicable Diseases................................................................ 10

Mental Health............................................................................ 12

Disability ................................................................................. 13

Essential Drugs .......................................................................... 13

Leading Issues

What Does a Basic Health Services Package Mean? ................................ 14

Vertical vs. Horizontal Programmes.................................................. 15

Levels of Care (the push down of services) ...................................... 15

Special Needs of Vulnerable Populations............................................ 16

Common Denominators

Community Education.................................................................. 17

Training................................................................................... 17

Health Information Systems ........................................................... 18

Operational Research .................................................................. 18

Programme Management .............................................................. 19

III. Managing the Health System................................................................... 21

IV. Recommendations

General Recommendations...................................................................... 27

Recommendations on Content .................................................................. 27

Recommendations on Management ............................................................ 28

Appendices

List of Contacts ................................................................................... 30

Bibliography ....................................................................................... 33

Abbreviations and Acronyms .................................................................... 34


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Executive Summary

Afghanistan's health system is in a state of near-total disrepair. Standard health indices, includingthe infant mortality rate, the childhood mortality

rate and the maternal mortality ratio, are amongthe worst in the world. As the new interimgovernment re-establishes and slowly strengthenssocial services, it finds itself facing a multitudeof technical, managerial and operational problemsthat need to be clarified before they can besolved. This report outlines the major issuescurrently facing the public health sector, discussesthe roles of government, United Nations (UN)agencies, donors, and non-governmentalorganisations (NGOs), and makes recommendationsfor how some of the more pressing problems might

be resolved.

Among the more glaring problems that continueto affect the ability of the TransitionalAdministration of Afghanistan to bring about rapidand lasting improvements in the health status ofits population are:

a grossly defic ient, even absent,infrastructure;

a health system that is top-heavy with doctorswho are not trained to deal with priority,

community-level problems, and who lackpublic health expertise;

poorly distributed resources;

health care delivered on a project basis bymany distinct, relatively uncoordinated serviceproviders, as opposed to health care deliveredin accordance with a clear and coherentnational health policy; and

lack of practical, useful and coordinatedinformation systems for management decision-making.

Despite these problems, there are positive factorsthat may allow the government and its partnersto make reasonably rapid progress. These includea relatively high level of government commitment,donor interest (at least for the present), technicaland financial assistance from the UN, a strongand committed community of NGOs and a (limited)record of successful implementation of publichealth programmes in the form of masspoliomyelitis and measles vaccination campaigns.

An April 2002 Joint Donor Mission (JDM) toAfghanistan considered options for re-establishingand strengthening the countrys public health

services. Its principal recommendations were todevelop a Basic Health Services Package thatwould form the essential content of the healthsystem and to manage the delivery of those basicservices through the development of performance-based, contractual agreements with NGOs.

The Basic Health Services Package, currentlyunder development by the Ministry of PublicHealth (MoPH) and its advisers, consists of sevenmajor elements:

Maternal and newborn healthChild health and immunisation

Public nutrition

Control of communicable diseases

Mental health

Disabilities

Essential drugs

At the time of this report, the cost of the proposedpackage had not yet been calculated. In addition,

there are several outstanding issues regardingprioritisation of the services in the package thatshould be explored further. For example, thoughmental health and disabilities are importantsources of morbidity and are deserving of theattention of the public health community, theyrequire a relatively high degree of specialisationfor intervention and make a small contributionto excess preventable mortality; they could, forthese reasons, be considered as secondarypriorities. Other issues include vertical versushorizontal programmes, the level of

implementation of various interventions and theneed to pay adequate attention to particularlyvulnerable populations.

Whatever the final composition of the Basic HealthServices Package, there are a number of activitiesthat are common to all of the proposedinterventions and services. These include healtheducation, training, operational research,information systems and programme management.With particular regard to the latter, the

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performance-based partnership agreements (PPAs)are discussed in detail. Their perceived advantagesand disadvantages are reviewed, andrecommendations are made in regard to theireventual implementation. The implications ofthese PPAs for each of the major actors the

Ministry of Public Health (MoPH), the donors, theUN agencies involved in health and the NGOs are detailed.

Although it will be quite difficult to make rapidprogress, this report concludes that there is reasonto be cautiously optimistic about the future ofAfghanistan's public health system and its abilityto improve the health status of its grossly

underserved population. The key elements fora successful public health programme in this post-conflict environment include the establishmentof realistic goals and objectives, the carefulprioritisation of services and activities and thedevelopment of efficient and effective

management and information systems that allowfor the close monitoring of progress or lack ofit at every level, from the community throughto secondary and tertiary care facilities. Butone can only be optimistic if the most importantprerequisites of all a stable government, peaceand security are assured.

Recommendations

The following recommendations on general issues of basic health policy and the content andmanagement of the Basic Health Services Package are derived from the many interviews conductedfor this report; several are already being implemented:

General Recommendations

1. The MoPH, together with its advisers, should develop specific policies and guidelines to governthe public health system in Afghanistan at an early stage of its development to allow allactors in the health system to work toward achieving the same goals and objectives.

2. The authorities in Afghanistan should consider convening a loya jirga that includes eachof the major groups of actors for health (MoPH, UN, NGOs and private practitioners) in themonths following the next JDM to exchange information and to ensure the investment of allrelevant groups.

Recommendations on Content

3. The MoPH should not set itself up for failure by promising to deliver more than it can. Itshould review the priorities of the Basic Health Services Package, particularly mental healthand disability services, and develop a schedule for phasing in its components, taking intoaccount the financial, technical and operational realities of the current situation.

4. Following the completion of appropriate studies, clear policy guidelines should be developedand enforced for the treatments of choice for pneumonia, malaria and malnutrition.

5. Primary care services should be pushed down to the community level.6. The needs of highly vulnerable populations, particularly returnees, the internally displaced

and conflict-and-drought-affected populations, should not be ignored.

Recommendations on Management

7. NGOs should be more involved in the next JDM and full participation of the donor community

should be assured.8. A representative delegation of the public health community in Afghanistan should be senton a study visit to Cambodia where the PPA scheme is currently being implemented.

9. Alternatives to province-wide PPA contracts for health services should be considered.10. The place of specialised, vertical programmes (e.g. tuberculosis control, leishmaniasis control,

and perhaps support and rehabilitation of the disabled) should be carefully reviewed.11. A functional health information system that emphasises accurate, timely and actionable

information should be created.12. A research agenda to inform policy-making and service delivery should be developed and

implemented, with particular emphasis on household health practices, care-seeking behavioursand household expenditures on health.

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1 These figures, cited in the Aide-Memoire of the JDM to Afghanistan on the Health, Nutrition, and Population Sector (9 April2002 draft), are attributed to the United Nations Childrens Fund (UNICEF) and the World Health Organisation (WHO). The lifeexpectancy figure is from the National Health Policy, February 2002. There is widespread agreement that available nationwidehealth statistics in Afghanistan are inaccurate, and the health status of the population, by all commonly used statistical indicators,is abysmal.

2 The international assistance community, to the extent that it is a community, includes multilateral and bilateral donors, UNagencies and the large and diverse group of national and international NGOs. Among these NGOs are those who have beenworking in Afghanistan for years and whose approach to assistance is for the most part developmental, those who arrivedduring the post-September 2001 emergency period and are primarily relief oriented, and combinations of the two.

3 The JDM was led by the World Bank (WB) and the World Health Organisation (WHO). Members of the team included representativesfrom Department for International Development (DFID), the European Union (EU), the United States Agency for InternationalDevelopment (USAID), the Asian Development Bank (ADB), UNICEF and the United Nations Population Fund (UNFPA).

When one considers the most frequently citedhealth statistics in Afghanistan infant mortality(165/1000 live births/year), maternal mortality

(1700/100,000 live births/year) and lifeexpectancy at birth (46 years) it would be easyto conclude that, for the future, the only way isup.1 However, without a carefully designed andexpertly managed public health system, an abilityto identify, address and monitor the most commonhealth problems of the population, and a way toensure the quality of both preventive and curativeservices, it is possible that Afghanistan will berelegated to the bottom of the UNDP HumanDevelopment Index for years to come. Thechallenges facing the re-development of

Afghanistans health system are well known andhave been frequently discussed in internationalcircles during the past six months. This reportfocuses specifically on the elements of the healthsector, as observed in May-June 2002, that requireadditional consideration and short- to-medium-term action to establish the conditions for effectivehealth system management and health caredelivery.

At the time this issues paper was conceived bythe Afghanistan Research and Evaluation Unit(AREU), there was great concern that the

international assistance community would adoptan urban-centred, tertiary care approach to healthsector re-development.2 Therefore, the key termof reference for the team was, to analyse theoverall approaches being adopted by theseagencies, particularly in relation to their adoptionof the public health model versus more curativeapproaches.

Shortly after their arrival, team membersdetermined that, for the most part, this concern

was unfounded. The draft Aide-Memoire of theJoint Donor Mission (JDM) to Afghanistan on theHealth, Nutrition and Population Sector was the

dominant document under discussion, and it hada clear and forceful public health orientation.3

The Aide-Memoire built upon the classical primaryhealth care orientation of the National HealthPolicy, written in February 2002. After reviewingthe principle features of the health system as itexisted in Afghanistan in early 2002, the Aide-Memoire strongly urged the redistribution ofhealth services to provide equitable access inunderserved areas, the development of astandardised package of basic health servicesthat would form the core of health care delivery

in all primary health care facilities (see SectionII), and the development of a set of measurableindicators that would allow for the regularmonitoring of progress toward clearly definedhealth sector objectives. All these are standardfeatures of the public health approach.

The most striking feature of the Aide-Memoire isits recognition of the limitations of the MoPHscapacity to deliver health services to its entirepopulation and the inefficiency of a civil-service-based health system in the form of itsrecommendation that a strong partnership be

developed between the MoPH and the privatesector. The pillar of this partnership would beperformance-based partnership agreements (PPAs)under which the government would contract withthe private sector (local and/or internationalNGOs and/or other private sector entities) forthe delivery of specified health services to thepopulation (see Section III).

In May 2002, the PPA proposal had been endorsedin principle by the Afghan Assistance Coordination

I. Introduction

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Authority (AACA) and by the MoPH, but had notyet been developed in detail nor adequatelypresented to the NGO community. The Aide-Memoire is honest and clear about the problems potential and real facing effectiveimplementation of its proposals, but a proposed

second JDM has been postponed until mid-July.In the interim, both enthusiasm and concern havebeen voiced by members of the NGO community.One of the roles of the AREU team was, by

default, to try to discuss the salient features ofthe proposal with the NGO community and othersin Kabul and in the eastern region, and to elicittheir reaction. Toward the end of thisconsultation, at the requestof some of the NGOs, theresearch team held ameeting to review the

important features of theproposed PPAs, and todiscuss them in light ofexperience gained in otherpost-conflict settings. Inaddition, a well-attendedformal debriefing forrepresentatives of theM o P H , t h e d o n o rcommunity, the UN agenciesand the NGOs was held todiscuss issues and findings.

This report presents thesefindings and observationsbased on the proposal ofthe JDM, the content of thecurrent Basic HealthServices Package, a reviewo f t h e p l a n s a n dprogrammes of a number ofdonors, UN agencies andNGOs, and other importantaspects of the health caresystem in Afghanistan.

The research for this reportwas limited in scope anddepth by a number ofimportant constraints.First, time did not allow theteam to contact as manypeople as anticipated.Although a large samplingof respondents fromgovernments, donors, UN

agencies and NGOs was interviewed, importantand influential commentators may have beenmissed. A list of persons contacted can be foundin Appendix A. Second, travel in Afghanistanwas quite difficult during the time of our research.Access to many areas was by plane and required

a lengthy stay-over in Peshawar or in Islamabad,Pakistan. For this reason, a four-day visit toJalalabad, of which most of two days were spenton the unpaved road connecting that city withKabul, was the only field trip undertaken.Although Nangarhar (the province in whichJalalabad is located) is one of the relativelyeconomically advantaged and, in terms of health

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care, one of the better served areas ofAfghanistan, and can therefore not be said to berepresentative of the rest of the country, the tripwas informative and enlightening in many respects.Third, the scope of work was broad. The teamfound most issues concerning food security and

food assistance to be beyond our capacity and soconcentrated on the management and deliveryof preventive and curative health servicesincluding, to a moderate degree, nutritionsupplementation programmes. Finally, the rapidturnover of international staff in most internationalagencies (UN and non-governmental) meant thatin many cases those to whom we spoke wererelative newcomers to Afghanistan (although theiragencies may have been in country for manyyears), and could not give information with thehistorical perspective that might have lent

additional depth to this report.

In spite of these limitations, this report coversthe main issues facing the re-development of thehealth sector in Afghanistan. We have dividedthe report into two main sections issuesconcerning the proposed content of the healthsystem, and issues affecting its management.Though those who are currently working inAfghanistan are far more familiar with these issues

and their potential consequences, this reportaims to provide a synthesis of the informationprovided by those we interviewed, through thedirect observations made in hospitals, basic healthcentres and maternal/child health (MCH) centres,and by consulting other documents and texts

before and during the trip to Afghanistan. Thegoal of the team was to produce a report to bothserve as a reference and help organise the currentissues for those currently working in the healthsector, and provide a short, digestible orientationfor those who have yet to arrive. Although itmay seem bold, where we feel comfortable doingso, we make recommendations for future action.This report is intended to be a positivecommentary on what has been done to date inthe short time that the Interim Administration(IA) has governed Afghanistan. These are dynamicand turbulent times in Afghanistan. The wayforward may frequently seem obscure and fraughtwith insurmountable obstacles, natural and man-made. We are cautiously optimistic about thefuture of the health sector in Afghanistan, alwayson the condition that: 1) there be peacethroughout the country; and 2) there be a stableand legitimate government capable of settingsound technical and managerial policies andcommanding the respect of those who will beresponsible for implementing them.




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Content

The recent JDM recommended a number of next

steps to the MoPH and its local partners. Notsurprisingly, because a standardised set of servicesis one of the hallmarks of the public healthapproach, one of the earliest of these steps wasthe definition of the essential package of servicesto be made available throughout the public healthsystem in Afghanistan. This basic package wouldbe responsive to epidemiological imperatives ofthe country, addressing those problems that areindicated by available data or by consensus opinionto impose the greatest burden on the populationin terms of morbidity and mortality. But

epidemiological criteria were not the only onesto be applied. The basic package would containonly those health problems for which safe andeffective interventions are currently available.It would seek an equitable balance between

interventions that are cost-effective and thosethat are important to a large segment of thepopulation (where there are differences between

the two). Finally, it would balance the qualityof health services with the extent to which thoseservices can be offered at the most peripheralareas of the system that is, low-cost, basicservices for all, versus more expensive, moresophisticated services for a relative few. In orderto help define the package, an Advisory Committeeto the MoPH has been formed. The Committeeconsists of the MoPH, the three UN agenciesinvolved in health (WHO, UNICEF, UNFPA), andManagement Sciences for Health (MSH), which isproviding technical assistance to the MoPH in the

areas of policy and management and which willsoon be initiating a grants programme to NGOsfor relevant health programmes andrepresentatives of the NGO community.The proposed package seems mostly reasonable

II. The Basic Health Services Package for Afghanistan

The Basic Health Services Package

In summary, the proposed Basic Package of Health Services contains the following components:4

Maternal and newborn health- Antenatal care

- Delivery care- Postpartum care- Family planning- Care of the newborn

Child health and immunisation- Expanded Programme on Immunisation (EPI) services (routine and outreach)- Integrated Management of Childhood Illnesses (IMCI)

Public nutrition- Micronutrient supplementation- Treatment of clinical malnutrition

Communicable diseases- Control of tuberculosis- Control of malaria

Mental health- Community management of mental health problems- Health facility-based treatment of outpatients and inpatients

Disability- Physiotherapy integrated in the Public Health Care (PHC) services- Orthopaedic services expanded to hospital level

Supply of essential drugs

4 As detailed in the May 2002 document, A Basic Health Services Package for Afghanistan Second Draft, Document for Discussion.

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in its content and addresses many (but by nomeans all) of the major public health problemsof Afghanistan. A detailed and well-reasoneddiscussion of each of the individual items, withappropriate questions regarding the extent towhich they can be implemented, is presented in

the draft document (e.g., which antigens shouldbe included in the EPIand what degree ofspecialisation is requiredfor the implementationo f menta l hea l thproblems). A large partof the document isdevoted to the deliveryo f t he d i f f e r e n tcomponents of the essential package at differentlevels of the health system community, health

centre and hospital.

The draft report also discusses the manyconstraints to the implementation of the proposedpackage, essentially concluding that, althougheach one of the components listed in the basicpackage proposed can be regarded as modest,providing the whole range of services has proventoo big a challenge for most developing countries.As confirmed by the MoPH, it will also prove toobig a challenge for Afghanistan in its current form.

At this early stage of redevelopment of the Afghan

health system, the adoption of modest goals andobjectives, rigorous prioritisation of interventionsand the strict discipline required to maintain afocus on a quite narrow range of activities areessential. The health status of the Afghanpopulation at this time is quite poor and it is asad but true reality that there are no quick fixes.Much can be done in a short time, but it is a nearcertainty that the health status of the populationwill remain poor for years to come. The bitterpill that must be swallowed by all those workingin the Afghanistan health sector is that even if

peace and political stability are achieved, thelegacy of 20 years of war and political instabilitythat resulted in the destruction of the healthinfrastructure of the county, and the failure todevelop an adequate cadre of technicallycompetent health workers will be present for theforeseeable future. The short-term and mid-termoutcomes of the numerous activities beingconducted in the health sector today, even ifthey could be highly coordinated, delivered in amost efficient manner and distributed equitably

throughout the country, can lead only to arelatively better situation, but not to a good one.A concerted effort over a long period of time iswhat will be required to bring down mortalityrates in a sustainable manner and return thehealth of the people of Afghanistan to the state

of health to which they have every right.

For a fuller discussion ofthe issues involved inthe implementation ofan essential package ofservices, the officialdocument, when it iscompleted, should beconsulted. Here we

highlight a few of the major considerations thatshould be taken into account for each of the

technical programmes currently underconsideration, and for the delivery of the proposedbasic package as a whole.

Maternal and Newborn Health

The maternal mortality ratio in Afghanistan, whileundetermined, is believed to be among thehighest, if not the highest, in the world. Themost quoted figure is 1700 maternal deaths per100,000 live births per year. A research study

A concerted effort over a long period of timeis what will be required to bring downmortality rates in a sustainable manner andreturn the health of the people of Afghanistanto the state of health to which they haveevery right.



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aimed at getting a more accurate figure formaternal mortality is currently being implementedby a team from the U.S. Centres for DiseaseControl and Prevention (CDC). The broadapplication of the Safe Motherhood Initiative (SMI)of the WHO and UNICEF, with particular emphasis

on the provision of emergency obstetrical care,is a proven intervention that could, in time, bringabout an important reduction in maternalmortality.

UNICEF recently conducted an assessment of theresource needs required to implement the SMI inAfghanistan. 5 The team made severalrecommendations that are generally applicableto all of the public health programmes that willbe included in the Basic Package of HealthServices. Specifically, they suggested that astrong and immediate emphasis be placed on the

training of intermediate and lower-level healthworkers, that technical and financial support begiven to NGOs working on the SMI, and that MoPHcapacity in the area of maternal and newbornhealth be strengthened.

In the medium term, it is interesting that theteam suggested that the principal objective ofthe SMI in Afghanistan be to increase theproportion of births attended by skilled healthpersonnel (trained and qualified traditional birthattendants (TBAs), auxiliary midwives, midwivesor female physicians). In order to achieve this

objective, they urged the development, byconsensus of the actors in the Afghanistan healthsystem, of a National Reproductive Health Policywith standards and guidelines for the delivery ofa minimum set of essential reproductive healthservices. The implementation of these servicesshould be closely and carefully monitored by thedevelopment and inclusion of a set of specificindicators in the routine health informationsystem, complemented by periodic, specialsurveys.

The team made recommendations regarding theprovision of antenatal care. These includedtetanus toxoid immunisation, supplementationof the diet of pregnant women with iron and folicacid and malaria prevention (but, notably, nomention is made of presumptive treatment formalaria twice during pregnancy in areas and at

times of high incidence an intervention that hasproven to be inexpensive and effective). Theteam also discussed health education about thedanger signs of pregnancy, delivery in the presenceof a skilled birth attendant, and emphasis onimmediate breastfeeding, including colostrum

and exclusive breastfeeding for six months.

But perhaps the most important of therecommendations, especially in the Afghanistancontext, is that emergency obstetrical servicesbe extended through the training and deploymentof appropriate staff. TBAs trained to recogniseobstetrical complications, close linkages betweenTBAs and local health facilities and regularmonitoring of TBA performance is crucial to thesuccess of the SMI initiative. Equally importantis the observation that Afghanistan currently hastoo many male physicians and not enough well-

deployed midwives, nurses and female physicians.This situation should be redressed in the mid-term future.

The level of care at which services could beoffered is not specifically discussed in the SMIreport. Maternal deaths from obstetricalcomplications are not predictable and can requiresophisticated care including parenteral antibiotics,blood transfusions and/or surgical delivery(Cesarean section). Because of the difficultiesof physically accessing health facilities, womenliving in remote areas may not be able to take

advantage of these services even if they areavailable at the hospital level. It is critical, ifmaternal mortality is to be reduced, that TBAsand other staff working in the community and atthe basic health centres be trained to recognisethe warning signs of complicated delivery, andthat they be able to quickly refer the patient toa level of care where comprehensive obstetricalcare is available. Strong consideration must begiven to training non-physicians in appropriatelife-saving obstetrical techniques, includingsurgery, as is being done with considerable successin a few other countries. It should also bementioned that it is not enough to havecommunity-level recognition of impendingproblems and facility-based competence to dealwith those problems. Transport between the twoneeds to be assured, and this poses a huge problemin Afghanistan.

5 Dalil S., Fritzler M., Ionete D., McIntosh N., OHeir J., Stephenson P. Assessment of Services and Human Resource Needs forthe Development of the Safe Motherhood Initiative in Afghanistan. Conducted by JHPIEGO for UNICEF/Kabul. 2 May 2002.

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The issue of pushing down services to the mostperipheral level of care and into the hands ofnon-physicians is discussed further below. It iscritical to the effective implementation of theBasic Health Services Package in Afghanistan.

Although the Basic Health Services Package groupsmaternal health and newborn care, there isrelatively little emphasis on the latter. Of course,ensuring tetanus toxoid vaccination duringpregnancy, together with the other elements ofthe SMI, would go far to improving newbornsurvival rates. Proper initiationa n d m a i n t e n a n c e o fbreastfeeding is of unparalleledimportance. However, in anycase, a high proportion of infantmortality occurs during thenewborn period (see below).

On the other hand, both thediagnosis and the treatment ofmany potentially fatal conditionsof the newborn are difficult,expensive and beyond the reachof most health facilities inAfghanistan. It would not beinappropriate, at this time, toconcentrate on reducing infantand child mortality from themost common causes of illnesses,and addressing the problems ofthe newborn period at a laterdate.

Child Health and Immunisation

More than one-fourth of children born inAfghanistan do not reach their fifth birthday.This appalling statisticis due to a variety offactors, which include:incorrect householdbehaviours (especiallyi n a d e q u a t eb r e a s t f e e d i n g ) ;incorrect treatment ofcommon, but potentiallyl i f e - t h r e a t e n i n gi l lnesses, such asdiarrhoea; little recognition of the early warningsigns of severe respiratory infection and severemalaria; poor health care-seeking practices;inadequate health care at the community/basichealth centre levels; and lack of access to healthservices.

Nevertheless, Afghanistan has recorded recentsuccesses in the area of childhood immunisation,extending polio vaccination widely throughoutthe country and making measurable progressthrough the implementation of a measles mortalityreduction strategy consisting largely of mass

vaccination campaigns. According to some, it isunlikely, at the time of this report, that manyAfghan children remain unvaccinated againstpolio, and the number of cases detected, evenin light of intensified surveillance, has beendecreasing. According to others, substantial

pockets of unvaccinated children remain.Nevertheless, it seems likely that importantprogress has been made over the last few years.If one can judge from the experience of othercountries in difficult circumstances, the successof National Immunisation Days may well eliminatepolio from Afghanistan in the next year or two

and make a majorcontribution to theglobal eradicat ioneffort. But eradicatingpolio will not contributeto reduc ing ch i ldmortality, to which thisd i s a b l i n g ( a n dsometimes fatal) diseasemakes a relatively smallcon t r ibu t i on . In

contrast, the implementation of the measlesmortality reduction strategy that targets childrenfrom the age of six months in specific geographicareas, combined with the delivery of vitamin Asupplementation to children less than five yearsold, can have a substantial impact, if sustained.

The implementation of the measles mortalityreduction strategy that targets children fromthe age of six months in specific geographicareas, combined with the delivery of vitaminA supplementation to children less than fiveyears old, can have a substantial impact, ifsustained.


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These vertical campaign-oriented programmeshave shown that, with appropriate guidance andassistance, the Afghan health system can performat a high level. But the ongoing provision ofroutine, community-based and facility-basedpreventive and curative programmes is, in some

ways, more challenging.

The major causes of childhood mortality inAfghanistan, in addition to measles, are diarrhoea,pneumonia and malaria, compounded bymalnutrition. For each safe, effective and cost-effective treatment canbe made available.These diseases are thes u b j e c t s o f t h eWHO/UN ICEF IMC Iinitiative.

The objective of IMCI isto address the majorcauses of childhoodmortality in an integrated, holistic fashion. IMCIworks

1. At the community level to promoteappropriate household behaviours;

2. At the basic health centre level to ensure theaccurate assessment, diagnosis and effectivetreatment of potentially life-threatening

diseases;

3. At the hospital level to provide tertiary careto severe cases; and

4. At the level of the health system to implementin-service training, regular monitoring andsupervision throughout the health servicesand periodic evaluation.

An essential element of IMCI is its training coursefor intermediate health workers. Following an

intensive initial study phase during which the keyelements of the IMCI treatment algorithm areadapted to the national/local context, trainingof health workers begins. The training course islong (13 days) and includes considerable practical(by-the-bedside) instruction. Experience has

shown that the number of health workers thatcan be trained in a short period of time is relativelysmall.6

Fortunately, the epidemiological characteristicsof Afghanistan may allow training of health care

workers in the appropriate care of the majorkiller diseases of children to proceed more rapidly.Although health workers trained in IMCI may beable to provide more effective clinical care, it isalso possible to provide training to address themost commonly occurring conditions. In

Afghanistan there aredistinct seasons, eachwith a characteristicd i s e a s e p r o f i l e .Diarrhoea and malariaare primarily diseases of

summer; pneumonia hasa higher incidence inwinter. Until theadaptation of the

generic IMCI programme can be completed anduntil a sufficient number of trainers can be trained,vertical, season-oriented training of clinic-based health workers and health educationmessages appropriate to the time of year shouldbe developed.

The need for this training (both pre-service andin-service) is clear. After 20 years of conflict,

Afghanistan has been left with an over-medicalisedcorps of health personnel that has not been ableto stay abreast of recent advances in knowledgeand medical practice. A bulletin, circulated byan NGO currently supporting health care inAfghanistan, quotes a professor of pediatrics assaying that cotrimoxazole, besides having norisk, is beneficial in controllingdiarrhoea inchildren. Both of these points are incorrect:cotrimoxazole, an inexpensive antibiotic, doeshave risks and is not effective for the treatmentof diarrhoea in children. Childhood diarrhoeal

deaths have been substantially reduced (by morethan one million per year) in developing countriesby abandoning the use of antibiotics and intestinaldisinfectants in favour of even less expensive,truly without risk, oral rehydration salts. Afghanhealth care professionals need to be trained in

Afghan health care professionals need to betrained in the use of modern, cost-effectiveinterventions, and these interventions needto be made available where they will havethe greatest impact: in, or as close as

possible, to the communities where thediseases occur.

6 This is true for most programmes that have large training requirements the SMI assessment cited above suggests that it wouldtake almost a year to develop a cadre of about 12 trainers who could then begin training midwives and auxiliaries in competency-based emergency obstetrical care. IMCIs training requirements are also quite burdensome. Building capacity is a slow process,and rushing it results in the delivery of sub-standard health care.

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the use of modern, cost-effective interventions, andthese interventions need to bemade available where they willhave the greatest impact: in,or as close as possible, to the

communities where the diseasesoccur.

Public Nutrition

The interventions specified inthe current draft of the BasicHealth Services Package aremicronutrient supplementationand the treatment of clinicalmalnutrition. The formerpre sumably means the

administration of vitamin Acapsules to children andiron/folate tablets to pregnantw o m e n . V i t a m i n Asupplementation has beenshown to reduce childhoodmortality due to a number ofdiseases including diarrhoea andpneumonia. It has become acommon intervention in tropicaldeveloping countries. InAfghan i s tan, v i tamin Asupplementation has been

provided, together with poliovaccines, during the NationalImmunisation Days. No studiesof vitamin A levels areavailable, but it is assumed,rather than documented, thatthere is a high prevalence ofvitamin A deficiency in children. However, anutrition survey in Badghis Province found arelatively low 2.6% of children with at least oneclinical sign of vitamin A deficiency.7 Othervitamin deficiencies, including riboflavin deficiency

and vitamin D deficiency (rickets), are at least apotential problem in Afghanistan, and outbreaksof vitamin C deficiency (scurvy) have beendocumented quite recently. Whether or notdietary supplementation with these vitamins willbe provided through routine prevention services

7 Woodruff B., Reynolds M., Tchibindat F., Ahimana C. Nutrition and Health Survey, Badghis Province, Afghanistan, February-March 2002. UNICEF/Afghanistan and U.S. Centres for Disease Control and Prevention. It should be mentioned, though, thatrecognition of the early stages of clinical vitamin A deficiency by relatively untrained workers may not be very reliable.


at MCH clinics and basic health centres is notclear.

All women should receive supplements of ironand folic acid during their pregnancies. Thisstandard intervention should be routinely initiated

and monitored at MCH clinics and by communityhealth workers (CHWs) and TBAs at the communitylevel. Compliance rates vary greatly and studiesshould be done to determine the degree to whichAfghan women are supplementing their dietsduring pregnancy. The prevalence of anemia in

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pregnancy should also be determined in differentregions of the country, as anemia is a risk factorfor maternal mortality.

The treatment of clinical malnutrition is not astraightforward issue. Malnourished children can

be detected through a system of growth monitoringand promotion when they are brought to a healthfacility for other illnesses, or through active,community-based nutrition surveillance. Manynutrition supplementation programmes arecurrently being supported by UNICEF andimplemented by various NGOs throughout thecountry. Most of these detect children who areless than 80% of the median weight-for-height ofreference populations and provide them withvitamin-fortified cereals and vegetable oil to takehome (programmes discussed provided two

kilograms for a two-week period). Althoughno one is sure whoactually consumes thefood supplements in thehome, the theory is thatincreasing the householdfood supply will allowthe child to eat moreand resume normalgrowth. Supplementary feeding programmes arecurrently being provided in a patchy distributionin Afghanistan. Their effect is not yet clear and

monitoring and evaluation systems are incomplete.

Although they are based on the detection of acutemalnutrition, a much more important problem inAfghanistan seems to be very high levels ofstunting, or chronic malnutrition (57.5% accordingto the UNICEF/CDC survey in Badghis Province).Underlying causes undoubtedly include poorbreastfeeding practices and inappropriatecomplementary feeding in children under sixmonths old and during the weaning period. Inother words, a lthough both v i tamin

supplementation of healthy children and pregnantwomen and the treatment of clinical malnutritionin children are appropriate elements of the BasicHealth Services Package, the important problemof chronic under-nutrition will not be adequatelyaddressed by them. Rather, important behaviourchange interventions in the area of child feedingalso need to be developed. An analysis of stuntingin Afghanistan using the widely-accepted UNICEFconceptual framework for causes of malnutritionmight be revealing.

Finally, an interesting phenomenon in Afghanistanis the documentation of relatively high levels ofchild mortality in the absence of high levels ofacute malnutrition. This unusual phenomenonshould be investigated and the potential role ofmicronutrient deficiencies explored.

Communicable Diseases

Malaria

Malaria is endemic in Afghanistan. As indicatedabove, it occurs seasonally, with transmissionfrom April-November throughout the country.Although most malaria is due to P. vivax, whichremains sensitive to chloroquine, about 15% isdue to P. falciparum, which is felt to make animportant contribution to child mortality.

P. f a l c i pa r u m i nAfghanistan appears tobe largely resistant tochloroquine, whichnevertheless remainsthe drug of choice.Resistance to sulfa-doxine/ pyrimethamine(SP) has been documen-ted at low levels and

needs to be carefully monitored.

Research into malaria prevention has been carried

out by HealthNet International (HNI), inconjunction with the London School of TropicalMedicine and Hygiene. Demonstrations of thecultural acceptability of impregnated bed netsand their effectiveness in blocking the acquisitionof malaria infection have led to large bed netdistribution programmes in parts of the country.HNI has been involved in the distribution of morethan 450,000 impregnated bed nets to date.Work is also being done on the effectiveness ofimpregnated clothing (chadors), on cattle spongingand on stocking ponds with the larvicidal fish, or

gambusiae, in an attempt to reduce mosquitobreeding sites.

However effective these technical interventionsmay prove to be, malaria control will depend onthe system of health services delivery that isdeveloped. At present, there appear to be twosystems for dealing with the occurrence of malariaat village level. In one, community health workersare taught to recognise the symptoms of malaria,but they are not allowed to provide treatment

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An interesting phenomenon in Afghanistanis the documentation of relatively high levelsof child mortality in the absence of highlevels of acute malnutrition. This unusualphenomenon should be investigated and thepotential role of micronutrient deficienciesexplored.


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As is the case with malaria control, the vaccinationcampaign and the proposed national micronutrientfortification programmes mentioned above,tuberculosis control in Afghanistan will require amix of specialised technical expertise andassistance at the higher levels of the system, and

well-informed strict implementation of nationalpolicies and strategies at the village and healthfacility levels. This mix of vertical andhorizontal programmes is discussed below.

Leishmaniasis

Other specialised programmes, even ones thatare currently being pursued in Afghanistan, arenot included in the Basic Health Services Package.Leishmaniasis is a serious, but not fatal, diseasethat occurs throughout large parts of Afghanistan,including urban areas. Though treatment isavailable, it is quite expensive and would haveto be provided through external funding for theforeseeable future. HNI is currently supporting

a leishmaniasis clinic in Kabul. WHO is alsoinvolved in disease control activities.

they refer suspect cases to the nearest healthfacility where the definitive diagnosis is made bymicroscopic examination of a blood smear beforetreatment is given.8 In the other, CHWs candiagnose and provide treatment (chloroquine isthe only anti-malarial currently proposed for use

at the community level in the draft Basic HealthServices Package). There are advantages anddisadvantage to each approach, but given thatthat severe P. falciparum malaria can kill within24 hours, combined with the difficulty that muchof the Afghan population has inaccessing health facilities, astrong case can be made forcommunity-level diagnosis andtreatment (see below).

Tuberculosis

Tuberculosis (TB) is generallyconsidered to be an importantcause of adult mortality inAfghanistan. Mortality is felt tobe disproportionately high inwomen because of their relativelack of access to care, especiallyfor chronic conditions such asTB. A number of agencies,including WHO, MedAir, GermanMedical Service, and MdecinsSans Frontires (MSF), are

running specialised (vertical)anti-TB programmes in differentparts of the country. Although the globallyaccepted Directly Observed Therapy Short-Course(DOTS) strategy is widely recommended inAfghanistan, and has been successful under thewatchful eye of the NGOs in some parts of thecountry, it will be a challenge to implement itwidely.9 As with so many disease controlprogrammes, success depends on accuratediagnosis of a large proportion of cases, anadequate and regular supply of effective drugs,and appropriate action at the community level.

Regular monitoring and periodic evaluation areindispensable.

8 For this system to work effectively, trained laboratory technicians must be available in all health facilities. Although HNI isundertaking an extensive programme of monitoring and reinforcing diagnostic capability, this is not being done on a nationallevel. In some areas, the use of newly available, very reliable, rapid diagnostic tests might be considered, although they are,at this point, relatively expensive.

9 DOTS involves a series of activities, ranging from diagnosis through monitoring of the TB situation and evaluation of programmeeffectiveness. The main feature of the intervention is the requirement that anti-tuberculosis drugs be taken under the supervisionof someone other than the patient a relative or community health worker, for example. The purpose of directly observedtherapy is to improve compliance rates.



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Blindness

The International Assistance Mission (IAM) is anNGO that specialises in eye care. It conducts eyecamps in parts of Afghanistan and provides surgicalprocedures, for a fee, in a variety of settings.

The services are clearly necessary and soughtafter, but require a high degree of specialisationthat is not apparently compatible with a moregeneralised primary health care approach. IAMis privately funded, to a large degree, by theChristofel Blinden Mission of Germany, and doesnot rely heavily on public resources.

HIV/AIDS

HIV/AIDS control is a subject that must figure inall discussions of public health. To date, no

formal activities are being conducted in this area,though some health education, mostly throughmass media, is said to be occurring. The MoPHhas not yet organisedi t se l f to addre s sH IV/A ID S and nomention is made of it inthe Basic Health ServicesPackage in any way.Yet, Afghanistan iscertainly threatened bythe introduction of theHIV virus, with so manypeople returning fromIran, Pakistan and othercountries. Recently, reports of the detection ofa number of cases have been circulating.Afghanistan is in a position to prevent thewidespread transmission of HIV/AIDS in itspopulation. But to do so it will have to organiseHIV/AIDS prevention activities and begin toeducate people about the modes of transmission.In a conservative, religious culture where sex is

not openly discussed, broaching the subject mustbe done in a sensitive, careful way. The time to

start HIV control activities is now. Informationregarding HIV seroprevalence may be availablethrough the International Committee of the RedCross (ICRC), or other NGOs that are supportingsurgical services (including blood transfusion) inparts of the country. Screening of blood collectedfor transfusion could be done on an anonymousand unlinked basis. Other opportunities for bloodscreening, such as antenatal care clinics, couldalso be used to establish a baseline seroprevalencerate and to monitor changes. Safe blood handling

and transfusion techniques, as well as universalprecautions in clinical settings, could be institutedin short order and should be.

Other Diseases

Consideration needs to be given to specialised,vertical disease control programmes that are notpart of the Basic Health Services Package. Otherprogrammes, including the detection and controlof diseases of epidemic potential, such as bacterialmeningitis, viral hemorrhagic fevers, typhoidfever and others that are known to pose a threatin Afghanistan, also need to find a place withinthe MoPH.

Mental Health

There is general agreement that mental healthproblems are highly prevalent in Afghanistantoday. After twenty years of conflict,

characterised by theuprooting of millionspeople and massivedestruction of privateand public property, andthe total disruption ofthe l i ve s o f twogenerations of Afghans,this is not surprising.

Several studies havedocumented high levelso f d e p r e s s i o n

characterised by various degrees of loss ofmotivation through suicidal ideation. There areundoubtedly many people in Afghanistan whowould benefit from psychotropic medications.In fact, the abuse of these sedatives is widelyreported. Opium abuse is also reported to be animportant problem, even among women. Inaddition, many people who do not requiremedication would benefit from a strong systemof social support through which they could be

helped to cope with the ongoing stresses to whichthey are subjected. But the majority of mentalhealth needs could probably be met by a returnto normal life. Community development activities,such as the opening of schools, the creation ofincome-generating activities and increased securityand stability, would probably alleviate the mentalhealth problems of the vast majority of Afghans.As of now, it is not clear what the mental healthinterventions of the Basic Health Services Packagewould look like. The assessment, diagnosis and

The majority of mental health needs couldprobably be met by a return to normal life.Community development activities, such asthe opening of schools, the creation ofincome-generating activities and increasedsecurity and stability, would probablyalleviate the mental health problems of thevast majority of Afghans.

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being, disability services be omitted from theBasic Health Services Package. Further studiesregarding the appropriate interventions atdifferent levels of the system and the cost ofproviding these services should be undertakenand the possibility of phasing in these services at

a later date considered. In the meantime, ICRCand the other agencies addressing the problemof disability should be encouraged to continuetheir activities, to expand them to rural hospitalsif possible, and to help the MoPH develop a long-term strategy for dealing with this importantproblem.

Essential Drugs

The selection of a list of essential drugs is alwayscontroversial. The medicines needed for the

implementation of the Basic Package of HealthServices are fairly straightforward. Choices needto be made with regard to antibiotics, antimalarialsand antituberculosis medications as a function ofthe epidemiological characteristics of the diseases,available finances and cultural acceptability.More difficult, though, is the inclusion of drugsthat do not correspond to the interventions ofthe Basic Health Services Package. The provision


JohnIsaacforUNICEF

treatment of patients requiring prescriptionmedications is definitely too specialised forimplementation at the community level andprobably surpasses the capacity of most basichealth centres. At best, one could recommendthat patients in need of specialised care be

referred to higher levels of the system. Althoughmental health problems were mentionedfrequently at the National Health Sector PlanningWorkshop in March, it is not clear that there isa safe and effective set of interventions currentlyavailable to deal with the problem through aprimary health care approach. NGOs currentlyengaged in psychosocial activities should makereports of their accomplishments public, andtechnical expertise should be sought for the designof mental health programmes that make sense inthe Afghan context.

Disability

It is well-known that physical disability thatinterferes with peoples abilities to earn moneyand to take care of themselves and their familiesis an important problem in Afghanistan. War-related disabilities, including mine injuries, havebeen important, but other causes of disability,including cerebral palsy and polio, are reportedby some to outnumber these by as much as fourto one. One of the most prominent agenciescurrently working in the area of disabilities thatwe were able to meet with in preparing this reportis the ICRC, which has been in Afghanistan since1986. ICRC works primarily with handicappedwar survivors, of which it estimates there areabout 200,000. UNDPs Comprehensive DisabledAfghans Programmes (CDAP), whose future is nowuncertain, covered a wider range of disabilitiesthan the ICRC. SERVE, the Sandy Gall AfghanistanAppeal, and a number of other agencies are alsoworking to provide rehabilitation services to thosein need.

It is not clear how disabilities will be included inthe Basic Package of Services. ICRC has expresseda desire to have the manufacture of prostheticand other devices decentralised from its sixcentres to more peripheral locations.Physiotherapy services could also be provided atperipheral facilities of the health system but, asis the case for mental health services, a certaindegree of expertise that would surpass the capacityof most basic health centres might be necessary.It seems reasonable to suggest that, for the time



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of these other essential drugs is of paramountimportance if the public health system is to retaincredibility and earn the trust of the public. Butit is important to choose only those medicationsthat can be safely and effectively used at thelevels of the system for which they are designated.

For the time being, 18 items are listed for useat the community level, ranging from condomsand gentian violet to cotrimoxazole and anti-tuberculosis drugs. Thirty-four items are listedfor the basic health centres and 65 for the ruralhospitals, including those used for anesthesia,the treatment of severe malaria and other tertiarycare problems.

In summary, the Basic Health Services Packageis a fundamental part of the public health approachto health system development in a post-conflict

setting. The package currently being debated inAfghanistan includes a number of interventionsthat are of indisputable priority, but it may bequite ambitious for immediate implementation.Some of the interventions that are currentlyincluded should be reconsidered. The MoPHsexpressed preference for phasing-in the packageshould be accepted and a schedule for thisprogressive introduction of services should beworked out soon. The MoPH has asked MSH tocost out the current package in its entirety. Thiscosting exercise should provide guidance to theMoPH and its partners in finalising the definition

of the package and its schedule of implementation.

Leading Issues

What Does a Basic Health Services

Package Mean?

During the course of discussions with MoPH,donors, UN agencies and NGOs, it became clearthat the concept of a basic package of servicesmeant different things to different people. For

some, the interventions in the Basic HealthServices Package should be the only ones to beimplemented in health facilities. For others,additional interventions, especially medical careof adult males, was important for the credibilityof the system. Other specialised services, suchas dentistry, eye care and so forth, were alsoseen as essential, though there was generalagreement that these might not be supportablethrough the national MoPH budget or donordonations to it. For others, the Basic Health

Services Package represented a minimumpackage of interventions that would beguaranteed at all appropriate levels of the healthsystem, but that would form only a core, not theentirety, of what would be available through thepublic health system. Finally, the view most

forcefully articulated by the few MoPHrepresentatives interviewed was that the BasicHealth Services Package represented what wouldbe available in the most underserved parts of thecountry those areas where, for the variety ofreasons mentioned throughout this paper, eventhese few essential interventions are not currentlyavailable. In other areas, especially urban areas,the MoPH would continue to try to provide thefullest possible range of services.

In fact, the strictest interpretation of the public

health approach would be that only those servicesthat are included in the Basic Health ServicesPackage should benefit from public funding. Adifferent set of interventions could be offered atdifferent levels of the system, of course.Nevertheless, all publicly funded health serviceswould be offered in strict conformance with thepolicies and strategies detailed by the MoPH andits implementation partners for addressing the(for now) seven areas. This concept, while difficultto swallow, is quite important if the healthindicators of Afghanistan are to improve.

Unfortunately, few Afghan health personnel aretrained in public health. An interview with sixKabul-based hospital physicians (one generalpractitioner, two internal medicine specialists,one ear, nose and throat (ENT) specialist, onedermatologist, and one OB/GYN/general surgeon)was revealing. Their concerns were entirelypatient rather than population oriented. Theyasked what one does for diabetes, forhypertension, for breast and/or cervical cancer,among other relatively common chronic diseasesof adults. As clinical practitioners, they expressed

the view that the lives of individuals affected bythese conditions are as important as those whosuffer from the more common conditions. TheMoPH, the staff of which is also drawn from theclinical community, is undoubtedly sympatheticto the sentiments expressed by the group ofphysicians described above.

And they should be. Making choices betweenpublic health programmes is a relatively detached,office-based activity. The ethical dilemma is

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much more real to the clinician who is faced withthe difficult task of telling a patient that nothingcan be done, even when effective interventionsare available in other parts of the world. Thissame debate is now being conducted in the globalhumanitarian literature. Afghan political and

health officials, together with their funding andimplementing partners, will have to decide on apolicy-making level what the Basic Health ServicesPackage means. Fundamentally, the choice isbetween a minimal core of activities that will beguaranteed throughout a health system that willcontinue to provide maximal care to all, no matterhow costly, and a small package of affordableservices that will provide the most care to themost needy people, but that will deny othersaccess to the care they need.

Vertical vs. Horizontal Programmes

Should the interventions included in the finalversion of the Basic Health Services Package beprovided by polyvalenthealth workers or byspecialists in the detailsof each programmeconcerned? That is,should every facilityhave a TB controloff icer, a malar iacontrol specialist, an

epidemiology (EPI)nurse, one or two people trained in IMCI, anutritionist, a physiotherapist, a mental healthpractitioner and so forth, or should one healthworker be capable of providing multiple services?Experience shows that programmes are more

effective when they have dedicated personneland a distinct management structure. On theother hand, having separate supervisors, vehicles,reporting systems and implementing personnelfor each programme is clearly duplicative andinefficient.

Obviously, specialists will not be available at thecommunity level, where most basic health carein Afghanistan will have to be provided. Here,there is no choice but to have a polyvalent workercapable of implementing a small core ofmanageable tasks. At the basic health centre aswell, staff will usually be limited, sometimes onlyto one male and one female worker. As one goesup the line, however, it may be possible toincreasingly specialise until, in the regional or

national MoPH, each programme should have anindividual responsible for formulating policy,testing and communicating strategies, overseeinga specific part of an integrated information system,coordinating training programmes and so forth.This kind of system, from central specialist to

peripheral generalist, might be called diagonal.It is clearly best-suited to the needs of Afghanistan,but the roles of each category of worker at eachlevel of the primary health care system will haveto be clearly specified and frequently monitored.

Levels of Care (push-down of services)

As implied above, one of the crucial tasks of theMoPH in regard to the Basic Health ServicesPackage will be to determine who can do what.As discussed in the maternal health section above,

physical access to services is a major constraintto primary health care in Afghanistan. In orderto partially overcome this problem, it seemsimportant to provide as many basic services as

possible where thehealth problems aremost prominent in thevillages themselves.However, some of theinterventions specifiedin the Basic HealthServices Package aresoph i s t i ca ted and

beyond the reach ofcommunity health workers. Opinion differs as towhich these are.

Nevertheless, it seems reasonable, in the Afghancontext, to recommend that the MoPH allow CHWsto treat certain conditions for which care mightnot be sought in a sufficiently timely manner atfixed health facilities. For example, training aCHW to diagnose diarrhoea and to provideinstruction to a mother in oral rehydration isobvious. Allowing diagnosis and treatment of

malaria in the community is perhaps moreproblematic: purists would insist on microscopicconfirmation of each case in order to minimisethe development of antimalarial drug resistance.However, one could allow CHWs to providechloroquine as a first-line treatment (most malariain Afghanistan is due to chloroquine-sensitive P.vivax infection). If clinical improvement is notnoted within 24 hours, patients can be referredto the basic health centre. Along the same lines,though strong objections have been raised in

Physical access to services is a majorconstraint to primary health care inAfghanistan. In order to partially overcomethis problem, it seems important to provideas many basic services as possible where thehealth problems are most prominent in thevillages themselves.




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some countries to allowing village volunteers totreat childhood pneumonia with antibiotics (usuallycotrimoxazole), this would be desirable inAfghanistan. Only time can tell if CHWs can learnto assess and diagnose pneumonia on the basisof rapid breathing, and to dispense antibiotics in

a way that is understandable to the caretaker.Finally, among these examples, the question ofwhether or not non-physicians should be allowedto perform surgery, especially Cesarean sections,is discussed above. The issue of level of care isquite important in Afghanistan's heavilymedicalised health system in which doctors havemaintained control over many interventions thatcould be performed by less highly-trained workers.The health system will probably have to becomemore flexible, more permissive and more creativein the future. Nevertheless, all new policydecisions, except those that have beenindisputably successful in other countries, shouldbe tested in pilot areas and evaluated beforetheir final adoption.

Special Needs of Vulnerable Populations

In addition to the development of a Basic HealthServices Package, an effective public healthprogramme makes sure that the needs of themost vulnerable segments of the population areadequately addressed. In Afghanistan, theseinclude returned refugees, internally displaced,

and drought-affected people. Basic needs,according to minimum standards as outlined indocuments such as the Sphere Project, must bemet.10 Population-based mortality and nutritionsurveys, such as those carried out in BadghisProvince and planned for the rest of Afghanistan,should be used to establish baseline rates. Whererates are higher than commonly acceptedthreshold values, rapid intervention in these areasshould be prioritised.

The number of returning refugees from Pakistanhas been far higher than predicted by mid-May2002 about 500,000 returnees had been registeredby UNHCR. UNHCR is providing up to US $100 perfamily (more for those travelling long distances),but unless adequate food, water and shelter areprovided to all along the path of return, thehealth status of this population could deterioraterapidly. Even later, unless returnees are re-

integrated into villages in rural Afghanistan thereis a risk that peri-urban shantytowns could develop,with the inadequate water and sanitation andrelative inaccessibility to health care servicesthat usually accompany these situations.

Finally, the plight of women in Afghanistan,featured prominently in many reports, shouldalso be highlighted here. Reproductive health,including family planning needs in addition tosafe motherhood is often neglected in the earlystages of health system reconstruction. Otherhealth problems, caused in part by the low statusof women in Afghanistan (e.g. high mortality fromtuberculosis) need to be identified and addressed.Finally, poor household health behaviours,including care-seeking behaviours, need to bechanged through intensive, but effective, healtheducation campaigns.

Afghanistan shares an important characteristicwith other post-conflict settings. Although it isstruggling to rehabilitate its structural and humaninfrastructure through the slow and steady processof development, it still has a substantial numberof pockets of vulnerability where relief, notdevelopment, should be the order of the day.The objectives of these two spheres of activity,the intensity of effort required to attain thoseobjectives, the technical interventions and thetimeframe for reducing excessively high rates ofmorbidity and mortality can be quite different.It is the job of the MoPH, the donors and theimplementing partners to address both relief anddevelopmental needs simultaneously. This willbe a real challenge for a country where politicalstability is still not ensured, where many donorshave expressed interest, but not yet commitment,and where many NGOs have institutionalphilosophies and capabilities that enable themto work in either relief or development, but notin both.

Common Denominators

One useful characteristic of the Basic HealthServices Package is that all of the interventionsthat will eventually be adopted in the final versionhave a common set of cross-cutting characteristics

10 According to information provided by one NGO, a direct correlation has been established between sub-standard quantities ofwater at the Chaman refugee camp in the Balochistan province of Pakistan and the incidence of bloody diarrhoea.

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that can be planned forat the national level.The content of thesefeatures will be differentfor each programmaticelement, but the skills

required to deliver thatcontent are similar.

Community Education

Although little data is available, householdbehaviours for health are said to be in need ofsubstantial change in Afghanistan. According toinformants of this report, prevention is rarelypracticed. This is true even of basic requirementssuch as breastfeeding, which is of reasonableduration, but is started late and is not exclusive

for an acceptable time. Recourse to traditionalremedies for almost all of the proposed diseasesof epidemiological importance are common, butare of questionable impact.

In general, care-seeking behaviour is not welldocumented. The proportion of people whoseprimary source of health care is in thetraditional/religious system, the privatemedica l/pharmacysector or the publichealth system is notknown at this time. Of

course, many peopleshop around for healthcare, moving between the systems or takingadvantage of the strengths of each.1 1

Research into the attitudes and practices of thepopulation regarding their own health and thatof their children could provide very usefulinformation for the planning and implementationof health education activities.

Both national and international NGOs are providing

a great deal of health education at MCH and basichealth facilities. But the communication of goodbehaviour is frequently not enough. Messagesneed to be reinforced on a regular basis, from

different sources, andi n i t i a l p o s i t i v ebehaviours need to bereinforced in a varietyof ways in order to bringabout lasting change.

The use of mass mediashould be explored.

There is a tradition of health education by radioin Afghanistan, especially through the REACHprogramming of the BBC. The Aide-Memoiresuggested the development of radio programmesfor women as a quick impact project, and UNICEFis currently planning to use radio for deliveringhealth messages. Again, the content of themessages can be varied, but the need for healtheducation at community level is pervasive.

Training

Building human capacity was probably the mostcommonly cited need of the Afghan public healthsystem. There are a number of reasons why humancapacity of the system is currently deficient.Medical education under the Soviet regime wasnot responsive to the public health needs of thepopulation. As evidenced by discussions with

Afghan doctors, theemphas i s was oncurative care andnotions of public health

are poorly developed.As mentioned above,

medical progress has not been well incorporatedinto Afghan medical schools. Salaries are verylow. There are real disincentives for doctors tomove to rural areas. Finally, there are too manydoctors in relation to other categories of healthworkers that might be better suited, for a varietyof reasons, to provide basic health services tothe population.12 Other important reasons forlimited capacity include the more general collapseof an already limited educational system,

compounded by the Taliban ban on girlseducation, and the brain drain of many of thebest and educated immigrating to the West.

11 The sectors themselves are not very distinct. In Kabul for sure, and undoubtedly elsewhere, all government doctors maintainprivate practices in order to augment their meagre salaries. Other cross-system activities also take place. Anecdotally, oneinformant told us that a mullah in the south of Afghanistan was known to give women injections of Depo-Provera upon request.

12 There are currently about 4,000 doctors in Afghanistan and another 7,000 medical students. This is undoubtedly more thanthe number of trained community health workers in the country. The primary health care pyramid has been stood on its head.

Building human capacity was probably themost commonly cited need of the Afghan

public health system.


Research into the attitudes and practices ofthe population regarding their own healthand that of their children could provide veryuseful information for the planning andimplementation of health educationactivities.



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To redress this situation, plans are beingimplemented to vastly increase the number ofmid-level health workers, including nurses,midwives and auxiliary midwives. Two- and three-year pre-service training programmes in Kabulare being heavily supported by USAID and UNICEF

and are being implemented by IMC and otherpartners. There are plans underway to extendpre-service training to the other major regionsof the country. Nevertheless, pre-service trainingis a long-term project.There is a need todevelop sound in-servicetraining programmes forall categories of healthworke r , i nc lud ingphysicians. Much of thiswork is underway andmore is planned, but for the most part it isoccurring in an uncoordinated and project-wisefashion. The MoPH should devise a coherenttraining strategy for implementation by NGOs andother partners. Again, content should be tailoredto the Basic Health Services Package.

Health Information Systems (HIS)

The other prominently mentioned deficiency ofthe Afghan health system on which all contacts

agreed is the quasi-total lack of usableinformation. As with so many other features ofthe system, some information is available on aproject-by-project basis, but little systematicallycollected data is used to formulate nationalpolicies and strategies or to guide programmaticactivities.

There are numerous surveillance activitiesunderway, though. The WHO/UNICEF-led polioeradication effort is a good example in this regard.

The polio surveillance effort should be expanded,and the system should be made to accommodatereporting on other important conditions. This isbeing planned. The measles mortality reductionstrategy has also made a concerted effort toimprove reporting. Nevertheless, reports ofdiseases, even when reporting is limited to asmall number of major conditions and diseasesof epidemic potential, are only helpful to a limitedextent. Process indicators, designed to informon the progress of programmatic strategies, also

need to be incorporated into effective healthinformation systems (HIS).

Most of the organised, coordinated, national-levelinformation activity is taking place through AIMS(Afghanistan Information Management Service),

an apparently successful innovation of UNDP andUNOCHA. Still, information that will be mostuseful in reducing the poor health indicators ofAfghanistan will be information that can be

collected, analysed,interpreted and used atthe most local levelpossible. It is gratifyingto see the extent towhich basic healthcentres and MCH clinics

(at least the ones wevisited) are aware of their geographical catchmentareas, their target populations and some of theircoverage results. This kind of local informationfor local use needs to be expanded throughoutall projects currently operating, and eventuallyto national programmes that intend to implementthe Basic Health Services Package.

Operational Research

Throughout this document the need for

information has been stressed. Targeted researchis important to the development of appropriatepolicy in post-conflict health systems.

In Afghanistan, little is known about the followingareas at the present time:

Household health practices, includingbreastfeeding, weaning, treatment ofchildhood illnesses;

Care-seeking behaviours;

Household expenditures on health by type ofprovider;

Levels of mortality and malnutrition;

Prevalence of major micronutrientdeficiencies, specifically iron, iodine andvitamin A;

Rates of seroconversion (development ofimmunity) to measles vaccine at six monthsof age;

Capacity to conduct appropriately selectedand designed research should be developedand donors should prioritise supportingoperational research and not just projectimplementation.

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Rate of impregnated bed net use in mostareas of the country;

Means of redistr ibuting resourcesgeographically;

Resistance to antibiotics and antimalarials;

Incidence, diagnosis, treatment andproportional mortality of childhoodpneumonia;

Seroprevalence of HIV in thegeneral population high-risksubsets; and

Cause of disability, includingland mine injuries, birthinjuries and motor vehicleaccidents, among others.

This list could be much longer,as additional problems arerecognised. Capacity to conductappropriately selected anddesigned research should bedeveloped and donors shouldprioritise supporting operationalresearch and not just projectimplementation.

Programme Management

The final element that all public healthprogrammes have in common is the need forstrong management. Policy formulation and thedevelopment of effective strategies are animportant part of management, but they need tobe complemented by strong oversight, periodicmonitoring and well-designed, constructiveevaluation. The MoPH is admittedly weak in thisarea and will require substantial externalassistance over the next few years. Some of thisassistance is already in place, at least for the

short term, but additional commitments by donorswill be required. Given the ideas currently beingproposed as to howservices would bedelivered in Afghanistan,the managerial role ofthe MoPH is paramount.

One f i r s t s tep ineffective managementis the definition of clear,

realistic objectives. The National DevelopmentFramework (NDF), seeking early results, mentionsthat child mortality in Afghanistan should be cutby half in two years, clearly an impossible dream.In post-conflict settings, the quest for rapid resultsin order to maintain the interest of the donors

has competed with the recognition that therebuilding of political, economic and social systemsis a slow process and that rushing things onlyincreases the likelihood of an unsatisfactory

outcome. While the health sector does not workin isolation and needs to be sensitive to politicalconcerns, decisions must be made as to what theMoPH is trying to achieve. Setting quantifiableobjectives will, to a certain extent, dictate theinterventions and strategies to be implemented.For example, setting a national objective of

mortality reduction of children and pregnantwomen requires different interventions than oneof ensuring minimum services in all areas of the

country, including those that are currentlyunderserved. Working in concert with theinternational communityto eliminate polio fromAfghanistan requires adifferent level ofresources and verydifferent strategies thantraining an adequatenumber of mid-levelhealth workers to

In post-conflict settings, the quest for rapidresults in order to maintain the interest ofthe donors has competed with the recognitionthat the rebuilding of political, economicand social systems is a slow process and thatrushing things only increases the likelihoodof an unsatisfactory outcome.


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provide basic services. Certainly a mix of processand outcome-oriented objectives can, and should,be developed. But no matter how many differentagendas they seek to accommodate, theseobjectives should be realistic, well defined andclearly articulated. Only then can a set of

appropriate interventions and strategies bedeveloped.

A word is in order regarding coordination, anotherimportant aspect of effective management,sometimes referred to as the slowest commondenominator. Coordination in Afghanistan hasbeen difficult to date.13 This has been true notonly between the actors, but within the groupsthemselves. The

afg - the public health system in afg

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