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Afghanistan Research and Evaluation Unit

Issues Paper Series

The Public Health System inAfghanistan:

Current Issues

Ronald WaldmanHomaira Hanif

May-June 2002

© 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 theAREU.

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 extensiveexperience 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 ofPublic Health. The thesis for her Masters in Health Science was on measuring maternal 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.

About the Afghanistan Research andEvaluation Unit (AREU)

The Afghanistan Research and Evaluation Unit (AREU) is an independent research institution thatconducts 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 AREU’s 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).

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

Executive Summary

Afghanistan's health system is in a state of near-total disrepair. Standard health indices, includingthe infant mortality rate, the childhood mortalityrate 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 mightbe 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 gross ly 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 country’s public healthservices. 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 health

Child 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” versus“horizontal” programmes, the level ofimplementation 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

Afghanistan Research and Evaluation Unit (AREU) i

The Public Health System in Afghanistan: Current Issues

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 – theMinistry 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 effectivemanagement 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.

RecommendationsThe 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 Recommendations1. The MoPH, together with its advisers, should develop specific policies and guidelines to govern

the 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 Content3. The MoPH should not set itself up for failure by promising to deliver more than it can. It

should 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 Management7. 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 sent

on 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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Afghanistan Research and Evaluation Unit (AREU)ii

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 Children’s 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 ofAfghanistan’s 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 theinternational 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 thedominant 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 deliveryin 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 MoPH’scapacity 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 bedeveloped 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

Afghanistan Research and Evaluation Unit (AREU) 1


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 proposedsecond 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, bydefault, 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 theimportant 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 f romgovernments, 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 requireda 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 andfood 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 lentadditional 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 textsbefore 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.



Content

The recent JDM recommended a number of nextsteps 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. Butepidemiological 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 betweenthe 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 theareas 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 inthe draft document (e.g., which antigens shouldbe included in the EPIand what degree ofspecialisation is requiredfor the implementationof menta l hea l thproblems). A large partof the document isdevoted to the deliveryo f t h e d i f f e r e n tcomponents of the essential package at differentlevels of the health system – community, healthcentre 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 Afghanhealth 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 ifpeace 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 stateof 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 thetechnical 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 emphasison 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 thetraining 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 thisobjective, 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 colostrumand 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 takeadvantage 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., O’Heir 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 massvaccination 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 smallcont r ibut ion . I n

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 someways, 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/UNICEF 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-threateningdiseases;

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 anintensive 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 careworkers 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 ofsummer; pneumonia hasa higher incidence inwinter. Until theadaptat ion 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 controlling…diarrhoea inchildren.” Both of these points are incorrect:cotrimoxazole, an inexpensive antibiotic, doeshave risks and is not effective for the treatmentof diarrhoea in children. Childhood diarrhoealdeaths 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 aspossible, 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. IMCI’s 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 thecommunities where the diseasesoccur.

Public Nutrition

The interventions specified inthe current draft of the BasicHealth Services Package aremicronutrient supplementationand the treatment of clinicalmalnutrition. The formerpresumab ly means theadministration 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. InAfghanis tan, v i tamin Asupplementation has beenprovided, 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 deficiencyand 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 initiatedand 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 canbe 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 twokilograms 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 andmonitoring 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 l though both v i taminsupplementation 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 p a 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 carriedout 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, orgambusiae, 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.

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, andwell-informed strict implementation of nationalpolicies and strategies at the village and healthfacility levels. This mix of “vertical” and“horizontal” 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 supportinga 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 useat 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 MédecinsSans Frontières (MSF), arerunning 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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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, noformal 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 t o addre s sH IV/A IDS 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 isnot openly discussed, broaching the subject mustbe done in a sensitive, careful way. The time tostart 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 ves 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 behelped 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 ata 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 theimplementation 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


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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 bereferred 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 people’s 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. UNDP’s 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


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-conflictsetting. 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 MoPH’sexpressed 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 definitionof the package and its schedule of implementation.

Leading Issues

What Does a Basic Health ServicesPackage 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. Forsome, 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 mostforcefully 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 publichealth 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 expressedthe 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 andhealth 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 malariacontrol specialist, anepidemiology (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 moreeffective 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 toperipheral 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 andbeyond the reach of

community 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 ofmalaria 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.



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 ina 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 skillsrequired 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 exclusivefor 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 privatemed i ca l /pha rmacysector or the publichealth system is notknown at this time. Ofcourse, many people“shop around” for healthcare, moving between the systems or takingadvantage of the strengths of each.11

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 providinga 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 oncurat ive care andnotions of public healthare 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 girls’education, 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 Afghanpublic 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.


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 UNICEFand 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 healthworker , 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 contactsagreed 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 we

visited) 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 forinformation 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 ibut ing 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 theshort 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 st 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 donorshas 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 ofmortality reduction of children and pregnantwomen requires different interventions than oneof ensuring minimum services in all areas of thecountry, including those that are currentlyunderserved. Working in concert with the

international communityto eliminate polio fromAfghanistan requires adif ferent 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 ofappropriate 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. There is potential for disagreementbetween different bodies of government, forexample, such as between the AACA and the lineministries, and between the several line ministriesthat have responsibility for the provision of healthservices, including theMoPH and the Ministryof Higher Education.T h e r e a r e o t h e rministries that areinvolved in health asw e l l . D o n o rcoordination is always apotential – and usuallya real – problem. Donorsconsulted during thecourse of writing this report seemed generallysatisfied with the level of informal donorcoordination, though most felt that the formalmechanisms which have been formed are lessproductive.

The UN agencies are, to a certain extent, vyingfor prominence. With different institutionalhistories in Afghanistan, and generally unprovenrecords, they are struggling to establishrelationships of trust with the government, donorsand NGOs. If the performance-based contractscheme (see Section III) is put into place, evenin modified form, the role of the UN agencies willbe further called into question. On the otherhand, given the lack of managerial and technical

expertise in the MoPH, it seems reasonable tosuggest that the UN agencies provide substantialassistance in at least an advisory, if not a moreactive, capacity. UNICEF seems particularlycapable of filling this role, and it has organiseda series of admirable research and programmaticactivities. These roles, including national levelinformation gathering through surveys and thedevelopment of routine information systems; thedesign and implementation of national leveltechnical intervention programmes, such as thoseplanned in micronutrient supplementation; safemotherhood and measles vaccination initiatives;and the assignment of technical advisers to theMoPH should continue. The desired role of theUN agencies in the health sector should be mademore explicit in the next JDM and funding forthese agencies should be allocated.

Finally, NGO coordination is in a typical state ofaffairs. There are a number of NGO coordinating

b o d i e s f o r b o t hi n te rna t i ona l andnational NGOs, and theneed to coordinate thecoordinators is an issuethat was mentioned byseve ra l o f t hem.Established NGOs andnew arrivals, relief-o r i e n t e d a n ddevelopment-oriented

NGOs, primary health care and specialisedagencies, government-funded and privatelyfinanced, all should be represented by thecoordinating bodies. This is difficult, if not impos-sible. In fact, one of the principal coordinatingstructures, the Agency Coordinating Body forAfghan Relief (ACBAR), has found itself performinga function of information exchange far more thanone of providing leadership and representationof the NGO “community.” While informationexchange is a clear necessity in the dynamic andconstantly changing situation of Afghanistan,NGOs do need to be included in the decision-making processes of government and the UN tothe degree that their presence in the field warrants.

13 See Stockton N., Strategic Coordination in Afghanistan. AREU, June 2002, and Schenkenberg van Mierop E., NGO coordinationand some other relevant issues in the context of Afghanistan from an NGO perspective. 9 April 2002.

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While information exchange is a clearnecessity in the dynamic and constantlychanging situation of Afghanistan, NGOs doneed to be included in the decision-makingprocesses of government and the UN to thedegree that their presence in the fieldwarrants.

Whatever the final content of the Basic HealthServices Package, delivering health services tothe population will pose an enormous challengeto the MoPH. Many of its facilities – from hospitalsto basic health centres – were destroyed over theyears. The rehabilitation and re-equipping ofthese structures will be a costly and time-consuming undertaking. Even locating them,taking stock of the personnel assigned to them,and making an inventory of the services offeredwill be difficult.

WHO, using its Health Mapper programme, hasmade one attempt to do so. An Infrastructureand Health Atlas of Afghanistan was produced inFebruary 2002. It details the location of theknown functioning and non-functioning basichealth centres, showing that the former areconcentrated for the most part in and aroundKabul and in the eastern region. Although theseare the areas of highest population density inAfghanistan, it is worth noting that the ratio ofbasic health centres to population ranges fromapproximately one per 40,000 in the central andeastern regions to approximately one per 200,000in the south. Nineteen districts had no healthfacilities at all. A more comprehensive, activesurvey of all health facilities and associatedresources is currently being planned by MSH. Itis scheduled to begin in July and to be completedin September 2002.

Even without a detailed inventory of facilitiesand health care personnel, it is clear to all thatwhile the more densely populated parts of thecountry may be adequately served, in quantity ifnot in quality, there is a woeful shortage offunctional health service delivery points andhealth personnel in most of the country. Forpersonnel, the unequal distribution of resourcesis true for all levels of care, from traditional birthattendants (of which there are only 30% of theestimated number required) to physicians (of

III. Managing the Health System

which more than 50% of the approximately 4,000are said to be in Kabul alone). Of Afghanistan’s33 provinces, only 11 currently have the capacityto deliver emergency obstetrical care.

The majority of health care in Afghanistan isprovided at present through NGOs. It is estimatedthat more than 80% of functional health facilitieshave some form of NGO involvement. The numberof NGOs working in the health sector is large, thescope of their work varies considerably and, forthe most part, they are undertaking to deliverservices in discrete project areas. NGOs areproviding support in the form of physicalrehabilitation of premises, equipment, salarysupport for personnel, training and direct servicedelivery. While some are working through MoPHand/or Ministry of Higher Education auspices,many have bypassed government structures andare operating independently (albeit withgovernment permission). While most NGOs areworking to provide general primary health careservices, some are quite specialised, for example,IAM for eye care, ICRC for surgical and orthopaedicservices, HNI for malaria and leishmaniasis control,MedAir and MSF for TB control, and others.

Although a number of NGOs are attempting toaddress the needs of particularly underservedareas in the central and southern parts of thecountry, the overall distribution of NGO activitiesis uneven, with a concentration in the urban areasand areas near the Pakistani border. Many NGOactivities began as cross-border operations,headquartered in Pakistan, and their reachextended only to the eastern and, to a lesserextent, the north-eastern areas of Afghanistan.The conflict over much of the past 15 to 20 yearsdictated which areas could be accessed by eventhe most daring organisations. Logisticalconstraints also played an important role indetermining the deployment of personnel andservices.

If an efficient and effective national health system is to be developed in the coming years, thefollowing four considerations will need to be addressed:

1. The lack of managerial and service delivery capacity within the MoPH;2. The lack of physical infrastructure and appropriately qualified personnel;3. The poor distribution of resources; and4. The relatively uncoordinated and undirected efforts of the NGOs that are providing the bulk

of health care services.



A draft of the Aide-Memoire of the JDM toAfghanistan on the Health, Nutrition, andPopulation Sector (9 April 2002) presented aproposal for resolving these problems. The JDMsuggested that basic services could be rapidlyextended to underserved areas (and throughoutthe country) by the adoption of a managementsystem structured around PPAs between the MoPHand the NGOs and/or other private sectorelements.

Under the PPA scheme, the MoPH would beresponsible for establishing health care prioritiesfor the Afghan population and defining a basicpackage of services (discussed above) that wouldform the core of health facility activitiesthroughout the country. Quantifiable, time-linkedtargets for improvements in health service deliveryand, presumably, population health status wouldalso be established. The MoPH would prepare“requests for proposals” from the NGO communityand invite competitive bids for contracts to provideessential health services to underserved areas.It is suggested that one contract be awarded perprovince, with the NGO contractee responsiblefor the provision of all health services – fromhospital management to community-level care.Awards would be made in a transparent manner.14

The NGO awardee would be paid on a per-capitabasis for the provision of health services, but onlyif its performance was acceptable in relation tothe predetermined indicators, as evaluated byboth the MoPH and independent audits.

The PPA scheme is seen to have the followingreal and potential advantages, as outlined in theAide-Memoire, which states that PPAs would:

• allow the government to take advantage ofthe presence of international and local NGOsin the health sector, to more clearly definea common set of services and to promoteadherence to a national health policy;

• establish a more formal, hopefullyconstructive, relationship between thegovernment and the NGOs;

• ensure a more equitable distribution of healthservices;

• contribute to the decentralisation of decision-making, by situating day-to-day operationsat the provincial level; and, perhaps mostimportantly,

• allow the MoPH to restrict its functions tothe management of the NGO contracts andto forgo, to a large extent, the direct deliveryof health services through a large andcumbersome civil service corps, if scaled-upto cover a substantial portion of the country.

The potential disadvantages of the PPA approach(some of which are outlined in the Aide-Memoire)are also numerous. Obviously, the burden ofdeveloping and managing large contracts isenormous. The MoPH does not possess the skillsto do so and substantial technical assistance wouldundoubtedly be required over a long period oftime. The potential for the award process to beinfluenced by personal relationships, bribes andother forms of corruption is always present. Thesystem will probably be expensive for thegovernment, since the NGOs constitute amiddleman that would not be present if the MoPHwere to provide services directly. (On the otherhand, preliminary results from the Cambodiaexperience show that household expenditures onhealth were lowered as people made greater useof the higher-quality, lower-cost public facilitiesand sought health care in the higher-cost privatesector less frequently). Finally, and especiallysignificantly in the Afghan context, monitoringand assessment of NGO performance, the principalelement of the contract, requires the regularcollection and analysis of accurate data, somethingwhich is essentially non-existent at present.The PPA approach in Cambodia is described inmore detail and the results of an early,independent evaluation are presented elsewhere.15

In brief, utilisation of facilities, especially by thepoor, antenatal care visits, tetanus toxoidimmunisation coverage and childhood vaccinations,all increased dramatically in the contracted

14 Although details are not given in the Aide-Memoire, when the PPA approach was implemented with the assistance of the ADBin Cambodia, each bid consisted of two proposals, one technical and one financial. A panel consisting of representatives fromthe MoPH, UN, and the NGO community judged the technical merit of each bid. When more than one bid was determined tobe technically acceptable, financial proposals were opened publicly and the contract awarded to the lowest bidder.

15 Bhushan, I., Keller S., Schwartz B. Achieving the Twin Objectives of Efficiency and Equity: Contracting Health Services inCambodia. ERD Policy Brief #6, Asian Development Bank, March 2002.

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facilities. Quality of care in both health facilitiesand hospitals also improved, though it is not clearwhat criteria were used to determine this. Finally,as mentioned above, though government costswere higher, household expenditures were lowerin the contracted districts than in control districts.

These results are encouraging, though they arecharacterised by the authors as “preliminary andindicative,” and no data regarding curative careare presented. However, it is not clear to whatextent the Cambodia experience can be replicatedin Afghanistan. Some of the implications of itsadoption for the various actors in the healthsector are outlined below.

It is extremely difficult to get hard data regardingthe cost of providing health services in Afghanistan.Wha t i s c e r t a i n ,however , i s t ha tex te rna l f und ing ,currently estimated at80%, will be required formany years to come.16

The Aide-Memoiree s t i m a t e d t h er e q u i r e m e n t f o rdelivering hospital andbasic health services tobe between US $230 andUS $310 million over the next five years, and therehabilitation and equipping of existinginfrastructure an additional US $100 million. TheWorld Bank will undoubtedly be one of the largestdonors to the PPA scheme and a funding proposalis currently being prepared. The EuropeanCommission (EC) is considering a contribution ofsimilar magnitude, perhaps about US $10 - $15million per year for the next five years (followingon a contribution of approximately 20 millioneuros this year). Other donors have not yetdetermined their funding levels for health, butit is expected that additional funding will becomeavailable from a considerable number of bilateraldonors. It will be needed.

Whatever final amount becomes available, a highdegree of donor coordination will also bedesperately needed. Although it has been

proposed in other countries that donors contributeto a common fund in order to allow ministries ofhealth to implement their national plans, thismechanism has proven difficult to put into practicefor a variety of reasons, mainly involving donorrequirements for accountability. Bilateral, directfunding from donors to NGOs can certainly bedone under the PPA scheme, as long as donorsrespect both the technical content of the MoPHnational plan for expanding services, i.e., theBasic Package of Health Services, and thecontractual agreements agreed upon by the MoPHand the NGOs. Extensive donor funding of a largevariety of activities and services outside of theBasic Health Services Package and/or funding ofNGOs based on criteria other than the performancecriteria developed by the MoPH can only serve toundermine the credibility of the MoPH and its

ability to manage thehealth sector, andinterfere with its abilityto achieve its objectives.If the principal actors inthe health sector are tobe the government asmanagers and the NGOsas implementers, therole of the three UNagencies (WHO, UNICEF,UNFPA ) t ha t a r e

currently involved in the health sector is calledinto question. Of course, they will continue tobe called upon to provide technical assistance tothe MoPH, both in the design of the contractterms and in the bidding process as well as intheir areas of technical expertise, but their roleas “lead agency,” or ”secretariat,” for the healthsector is less clear. Whether or not animplementing function would be reserved forthem in the national vaccination programmes,other areas of communicable disease control,nutrition and safe motherhood, would need tobe worked out. It should be mentioned that atthe time of this report no UN agency had yet beendesignated as the overall secretariat of the healthsector.17

When this report was being prepared, the NGOswere, for the most part, uninformed about the

16 Report of the National Health Sector Planning Workshop (16-19 March 2002). Ministry of Public Health.17 After data had been collected for this report, but during its preparation, WHO was designated as the secretariat for health and

UNICEF was given responsibility for nutrition, childhood vaccinations and safe motherhood. UNFPA will be responsible forreproductive health in general.

Extensive donor funding of a large varietyof activities and services outside of the BasicHealth Services Package and/or funding ofNGOs based on criteria other than theperformance criteria developed by the MoPHcan only serve to undermine the credibilityof the MoPH and its ability to manage thehealth sector, and interfere with its abilityto achieve its objectives.



JDM proposal. At therequest of a number ofthem, a meeting washeld to present, albeitb r i e f l y a n dincompletely, the mainpoints of the PPA asdescribed in the Aide-Memoire and the Cambodiaevaluation report (see above). From this meeting,and from interviews with individual representativesof a considerable number of NGOs (see AppendixA for a list of interviewees), it was clear that theNGOs recognised the problems that the PPAscheme is meant to address. There was consensusthat the proposal had considerable merit on paper,but there were questions regarding the feasibilityof its implementation in the Afghanistan context.This was true even with the understanding thatin a competitive bidding process there would be“winners” and ”losers,” and that the systemseemed to favour those larger NGOs that hadlonger experience in Afghanistan. Some NGOsresponded favourably to the idea that it mightbe to their advantage to form formal or informalpartnerships with others working in complementaryareas in order to be more competitive. It shouldbe pointed out, though, that the sample of NGOs,(both international and national), interviewed aspart of this analysis is hardlyrepresentative of the large NGOcommunity currently working inthe health sector in the country.

Perhaps the most importantobservation from the NGOs isthat, like the government, theyalso do not possess the capacityto provide even basic servicesacross the levels of the healthsystem on a provincial basis.Even the largest of the healthproviders in the country, theSwed i sh Commit tee fo rAfghanistan (SCA), supports onlybasic health centres. Thoughtheir representative expresseda positive attitude toward thegovernment cont rac t ingapproach, recognising that it was

a way to increasegovernment control andto unify a fracturedhealth system, he feltthat SCA would have tol im i t i t s cu r ren tgeographical scope in

order to provide services at more than one levelof the system. Similarly, other NGOs expressedreluctance to take responsibility for the deliveryof services over a large area. Different NGOssuggested that contracts be limited to the provisionof services at specific facilities, on a district-by-district basis, or for a cluster of districts wherethe number of facilities within a district wasparticularly small.

It was suggested that NGO representatives sitwith the MoPH when the technical terms of thecontracts and the performance indicators arebeing designed. NGOs, by virtue of working atthe community level, may have a better idea ofthe kinds of services that are most required andmost desired by the communities, of the mosteffective service delivery strategies, and ofreasonable expectations for performance. Leavingthe MoPH and its advisers in complete charge ofthe design process, it was suggested, would be

17 After data had been collected for this report, but during its preparation, WHO was designated as the secretariat for health andUNICEF was given responsibility for nutrition, childhood vaccinations and safe motherhood. UNFPA will be responsible forreproductive health in general.

Perhaps the most important observation fromthe NGOs is that, like the government, theyalso do not possess the capacity to provideeven basic services across the levels of thehealth system on a provincial basis.

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a “top-down” approach that should be avoided.Similarly, it was pointed out that the perceivedadvantage of decentralisation accorded to thePPA scheme might, in fact, be a detriment. NGOsreported that local health officials, at provinceand district levels, already see themselves asbeing “in charge.” Unless they were part of thecontracting process and fully informed of theagreements made between the NGOs and theMoPH, central and provincial MoPH authoritiesmight have different sets of demands andrequirements. Improved and effectivecommunications between the different levels ofthe MoPH would have to be established. Finally,the acceptability of a formal contractualagreement with government in light of theadvocacy and witnessing role of NGOs and theirfunction as independent observers of the scenein a country as politically complicated and asfragile as Afghanistan was mentioned.

The experience of one NGO with which the PPAproposal was discussed in some detail, HNI, isworthy of mention for a variety of reasons. Forone, HNI is currently implementing two PPAagreements in Cambodia and has considerableexperience with the system. HNI is also currentlysupporting two distinct kinds of programmes inAfghanistan. One is a primary health careprogramme in Shinwar district in NangarharProvince in the eastern region. HNI is providingsupport to the University Hospital at the regional(provincial) level, to a rural 40-bed hospital inGhani Khel that serves a cluster of districts witha population of approximately 300,000, and totwo basic health centres that form the base ofthe PHC pyramid, or “cluster.” The other majorH N I a c t i v i t y i nAfghanistan is technicalsupport to malariacontrol. A specialisedt e a m h a s b e e npromoting, monitoringand evaluating the useof impregnated bed netsand other materials,cattle sponging andlarva-eating fish. Theyhave been researching

and monitoring antimalarial drug resistancepatterns and contributing to the development ofnational malaria control policies.

The primary health care “cluster” seems tailor-made for the PPA process, assuming that theperformance indicators are designed accordingto reasonable expectations that might be informedby the HNI experience (and others) to date.Interestingly, HNI reports that the initial contractsin Cambodia significantly underestimated therapid increase in utilisation of government facilitiesthat took place after the NGO contracts wereawarded. As a result, because the contractualpayments were made on a per-capita basis forservices offered, and because they had to servea substantially greater number of people thanthat for which they had contracted, HNI lost aconsiderable amount of money. They urge thatsafeguards be built into the contracts inAfghanistan until appropriate baselines can beestablished. Nevertheless, and in spite of thefact they their contract gave them onlymanagement oversight, not control, of healthservice delivery in their districts, HNI feels thattheir experience was quite positive.18 Theyrecognise the advantages in the short- to medium-term of a small, but capable, MoPH that wouldbe involved in policy making, monitoring andsupervision, but to a much lesser extent in servicedelivery. Similarly, they feel that a public/privatepartnership system would allow for systems to be“jump-started” in order to provide services intorural areas quickly. Finally, the closer involvementof NGOs with the MoPH at a national level wouldallow for capacity-building and an eventual, butunforeseeable at this time, transfer of

responsibilities back tothe government.

On the other hand, therole of the technical,“vertical,” malariaprogramme is less clear. HNI tries to providetechnical support to allgovernment and NGOmalaria control effortsat present. Technically

18 In Cambodia, two kinds of contracts were offered: In one, “contracting-in,” – the kind HNI had – NGOs gave technical andmanagerial support to civil service staff and inputs were provided through normal government channels. HNI reportedly haddifficulties with drug deliveries, timely payment of salaries, etc. In the other, “contracting-out” model, NGOs had completecontrol over resource provision and health service delivery, and they hired their own staff.

Although a sense of urgency is conveyed bythe aide-memoire and calls are made for“quick” and “rapid” action, a longer-termvision might serve the country best. Thelimited existing capacity on the part of bothgovernment and NGOs, the multiplicity ofactors and the cautious eye through whichmost donors are viewing the current situation,suggests that a slow, phased-in approachmight be more warranted.



specialised programmes, such as HNIs and othersmentioned above, are not currently provided forin the PPAs. They need to be.

In summary, the PPA proposal of the JDM seemsacceptable to the principal actors in Afghanistan’shealth sector and seems, in principle, to addresssome of the major existing problems. At thisstage, its designers need to be further informedof the characteristics of Afghanistan’s politicalstructure (when that becomes clearer and morestable) and the capacity of its line ministries.Although a sense of urgency is conveyed by theAide-Memoire and calls are made for “quick” and“rapid” action, a longer-term vision might servethe country best. The limited existing capacityon the part of both government and NGOs, themultiplicity of actors and the cautious eye throughwhich most donors are viewing the currentsituation, suggests that a slow, phased-in approachmight be more warranted. They also need to

understand better the capabilities and limitationsof the proposed principal partners to the MoPH:the international and national NGOs that arecurrently providing the majority of the healthservices. The NGOs need more informationregarding the current proposal and the pastperformance of PPAs, its benefits anddisadvantages, and its short- and longer-termimplications for their work in Afghanistan andelsewhere. Although there is little doubt thatwhen large contracts are offered, manyorganisations will be tempted to bid, it would bein the best interests of the MoPH to ensure thatthe larger and the most proven of the NGOs arewilling to participate. In order to ensure theirfull participation, the next JDM should try to elicittheir full participation, at least at a publicdiscussion of the proposal. It would also beconstructive for the JDM to provide a number ofalternatives to the scheme that is currently underdiscussion.

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Many of the above recommendations are derivedfrom interviews conducted for this report, andseveral are already in the process of beingimplemented.

General Recommendations

1. The MoPH, together with its advisers, shoulddevelop specific policies and guidelines togovern the public health system inAfghanistan at an early stage of itsdevelopment in order to allow all actors inthe health system to work toward achievingthe same goals and objectives. At present,most health care delivery in Afghanistan isdone on a project-by-project basis. NGOs orother entities, including UN agencies involvedin health design, seek funding for andimplement ideas that they feel meet theneeds of the population in accordance withbroad guidelines laid down by donors.Although the MoPH has issued an excellentstatement of general principles that clearlyarticulates the primary health care approach,there are no specific policies regarding primaryhealth care programmes that can guide theactivities of health service deliveryorganisations or coordinate their actions.The elaboration of a Basic Health ServicesPackage is a step in this direction.

2. The authorities in Afghanistan shouldconsider convening a “loya jirga” for healthin the months following the next JDM. Thismight take the form of a meeting ofrepresentatives of each of the major groupsof actors - MoPH, UN, NGO, and privatepractitioners - for a true exchange ofinformation and the joint development ofpolicy and implementation guidelines.Communications between the actors has beena problem. There have been attempts tocoordinate the activities of the NGOs, UNorganisations and the government throughformal and informal mechanisms ofinformation exchange. However, these havenot been effective, and there has beeninsufficient communication between thesecategories of contributors to the health

IV. Recommendations

system. In other post-conflict settings it hasbeen useful to have periodic, general meetingsto review and discuss health policies todevelop consensus around future activitiesand to hear about obstacles from the field.These meetings serve to keep everyoneinformed, to create a spirit of cooperationand consensus and to promote a participatorystyle of work. Ensuring the investment of allgroups in the future of public health inAfghanistan would be a first step in ensuringits success.

Recommendations on Content

3. The Ministry of Public Health should not setitself up for failure by promising to delivermore than it can. Although the draft BasicHealth Services Package is an important steptowards prioritising the essential work of thehealth system, there are enormous competingdemands for more than the system can handle.No one ever feels comfortable designatingimportant areas of work as “non-essential.”Yet the hard reality is that according to mostof those interviewed during this consultation,the Basic Health Services Package, as it iscurrently composed, cannot be implemented,at least not all at once. The MoPH shoulddevelop a schedule for phasing in thecomponents of the package and a review ofpriorities, particularly mental health anddisability services, taking into account thefinancial, technical and operational realitiesof the current situation. However, donorsshould understand that in order to be credible,the MoPH will have to try to satisfy the needsof its entire population. NGOs should try toensure that the appropriate technicalexpertise is available to deal with thoseproblems that are designated as highestpriority.

4. Following the completion of appropriatestudies, clear policy guidelines should bedeveloped and enforced for the treatmentsof choice for pneumonia, malaria andmalnutrition. The management of commonchildhood communicable diseases and



malnutrition should be the subject of anintens ive tra in ing programme forintermediate-level and community-basedhealth workers. While implementation of theWHO/UNICEF IMCI initiative would be ideal,the process is time-consuming and quitetraining-intensive. On an interim basis,shorter, more focused training efforts can belaunched to take advantage of the seasonaloccurrence of some of the target diseases.

5. Primary care services should be “pusheddown” to the community level. This includesthe management of diarrhoea, the initialtreatment of malaria and pneumonia and theassessment and referral of obstetricalemergencies. The level at which primaryhealth care services are offered is a crucialissue in Afghanistan because of the difficultyin accessing facility-based services. Such anapproach will require that non-physicians usedrugs and perform procedures that havepreviously been restricted to medicalpersonnel. Because women are often moreadept at community health work, includingvaccination, an appropriate proportion ofwomen should be trained to do these jobs.The issue of payment to community healthworkers for performing these services alsoneeds discussion and resolution.

6. The needs of highly vulnerable populationsshould not be ignored. Although the currentemphasis is on rehabil itation anddevelopment, there are a considerable numberof returning refugees, internally displacedand conflict- and-drought-affected populationswhose needs may be different from those ofmost Afghans.

Recommendations on Management

7. NGOs should be more involved in the nextJDM and full participation of the donorcommunity should be assured. NGOs arerelatively uninformed regarding the detailsand the implications of the PPAs, the principalfeature of the JDM's recommendations.Bilateral agreements between donors andimplementing NGOs should be allowed andencouraged, but the donors should respectthe programmatic priorities of the MoPH and

not pursue their own policies and programmesindependently. Competition betweengovernment and international donors can beavoided if donors are committed to the sameprinciples as the MoPH.

8. A representative delegation of the publichealth community in Afghanistan should besent on a study visit to Cambodia wherethe PPA scheme is currently beingimplemented, and where there is substantialexperience in rehabilitating post-conflicthealth systems.

9. Consider alternatives to province-widehealth services. At present few, if any, NGOsare capable of implementing health servicesat a provincial level in Afghanistan, assuggested by the PPA scheme and proposedin the draft Joint Donor Mission Aide-Memoire.Alternatives may include contracting serviceson a facility-by-facility basis (or for a clusterof facilities), contracting at a district levelor lower, or contracting several NGOs toprovide services at different levels of thesystem within a single province.

10. The place of specialised, verticalprogrammes should be carefully considered.NGOs that are not providing general primaryhealth care services, (e.g. tuberculosis control,leishmaniasis control, and perhaps supportand rehabilitation of the disabled), areproviding valuable services. The MoPH shouldoversee and manage these activities. NGOsworking in these areas should be accountableto the MoPH and to the public they serve.

11. A functional health information systemshould be created, emphasising accurate,timely and actionable information. It shouldbuild on the surveillance systems that havebeen put in place by the polio eradicationinitiative, though indicators of maternalhealth, nutrition and food security andprogrammatic (process) indicators for allpriority health activities will require differentinformation parameters.

12. A research agenda to inform policy-makingand service implementation should bedeveloped and implemented. Operational

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research is frequently neglected, and becauserelatively little is known about householdhealth practices, care-seeking behaviours,and household expenditures on health inAfghanistan, particular emphasis should beput on these subjects. Other potential priorityresearch areas are found in the body of thisreport.

The public health system in Afghanistan has along way to go if the health parameters of the

Afghan population are to improve. A concerted,long-term partnership between government,donors, UN and NGOs is a prerequisite forcontinued progress. These recommendations areoffered in the spirit of fostering as comprehensiveand as participatory a process as possible. Withthe sustained commitment, dedication, andintensive effort of those involved in public health,the health status of the Afghan population canimprove substantially over the next few years.



List of Contacts

Afghan Assistance Coordination Authority (AACA)

Leader, Nicholas, Representative

Ministry of Public Health (MoPH)

Fahim , Dr. Abdullah, Director of InternationalRelations

Ibrahim, Dr. Fazel M., Regional Director for theEastern Region, Jalalabad

United Nations

Borrel, Annaliese, Technical Adviser to the Ministryof Health, UNICEF

Crowley, Joe, Field Officer, AfghanistanInformation Management Service (AIMS - UNDP)

Fleerackers ,Yon, Epidemiologist, WHO

Gachiri, Joyce, Director Sub-Regional Office,UNICEF (Jalalabad)

Grandi, Filippo, Chief of Mission, UNHCR

Hanna, Iskandar N., Polio Programme Consultant,WHO

Huff-Rousselle, Peter, Country Representative,UNFPA

Ionete, Denisa-Elena, Project Officer, Maternaland Child Health, UNICEF

Modol, Xavier, PHC Consultant, WHO

Mojadedi, , Farooq National EPI Trainer, WHO

Momin, A. M. Deputy WR, WHO

Salama, Peter, Head of Health and Nutrition,UNICEF

Appendix A

Governments & Donor Institutions

Cautain, Jean-Francois, Programme Coordinator,EC

Freckleton, Anne, Programme Manager, DFID

Hayward, John, Head of the Office, ECHO

Jacob, Francoise, Correspondent, ECHO

Kvitashvili, Elizabeth, General DevelopmentOfficer, USAID

Lynch, Ellen, Health Officer, USAID (IOM)

Paro, Amy, USAID/OFDA

Sondorp, Egbert, EC

Tully, Anne, World Bank

NGOs

Anastacio, Anita, Country Director, Mercy CorpsInternational (MCI)

Andersson, Hans Ronny, Health Delegate, ICRC(Jalalabad)

Brigham, David, Programme Coordinator, IMC

Combes, Jerome, Head of Mission, Action Contrela Faim (ACF)

Coux, Isabelle, Médecins du Monde (MDM)

Douilliez, Caroline, Communication Delegate,ICRC

Durrani, M. Naeem, Technical Coordinator, Malaria& Leishmaniasis Control Project, HNI (Jalalabad)

Dutreix, Georges, Head of Mission, MSF

Erasmus, Panna, Programme Director, Malaria &Leishmaniasis Control Project, HNI

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Gardezi, M. Asif, Senior Health Field Officer, ICRC

Ickxx, Paul, MSH

Jabarkhail, Anwarulhaq, Country Director, IMC

Mindling, Tim, Deputy Executive Director,International Assistance Mission IAM

Nassiry, Ashraf and Stanekzai, Masoom, Agencyfor Rehabilitation and Energy Conservation inAfghanistan (AREA)

Newbrander,William, MSH

Noorullah, Ihsan, Regional Coordinator, Ibn Sina(Jalalabad)

Norwegian Afghanistan Committee (NAC,Jalalabad)

Purves, Ian, Executive Coordinator, ACBAR

Solter, Steven, MSH

Van Eijsden, Nicolien, Administrator, HNI(Jalalabad)

Wann, Jan-Erik, Regional Director, SCA

Wilder, Andrew, Director, AREU

Afghan Doctors

Jalil, Dr. M., Internal Medicine, Jamuriat Hospital

Joyenda, Dr. Feraidoon, Internal Medicine,Ibn Sina Emergency Hospital

Musly, Dr. Gulnoor, Obstetrician & Gynecologist,Rabia Balkhy Hospital

Parwani, Dr. Wakil, Dermatologist, Ibn SinaEmergency Hospital

Sadat, Dr. Said Abdullah, General Practitioner,Ibn Sina Emergency Hospital

Safi, Dr. Hafizudin, Chief of ENT, Ibn SinaEmergency Hospital

Meeting with NGOs Concerning PPAs

Anastacio, Anita, Representative, MCI


de Jong, Esmee, Liaison Officer, HNI

Oberircher, Dan, Representative, IAM

Hashimi, Dr., Medical Coordinator, MRCA

Hamid, Dr., M.H. Engineer, NCA

Jain, Valli, MCH Coordinator, Hope Worldwide

Karlsion, Marie, Programme Manager, Medair

Krueger, Alexander, Policy Adviser, Oxfam

Leader, Nicholas, Representative, AACA

Mohammad, Dr. Taj, Junior Health Liaison Officer,TDH

Pickwitt, Sarah, Health Coordinator, Oxfam

Tournieroux, Marie Laure, Project Coordinator,AMI

Wulf, Annette, Programme Assistant, GAA

Young, Nigel, Country Manager, Merlin

Attendees at Debriefing

Amiri, Dr. Mirwais, Family Planning Trainer, CHA

Anastacio, Anita, Representative, MCI

Ansari, Amir M., Health Officer, UNICEF

Asifi, Frozan, Women’s Activities Facilitator, CARE

Askar, Engineer M., Income GenerationCoordinator, CARE

Bang, Carol, Programme Officer, IMC

Benjamin, Judy, Gender Adviser, USAID


Brown, Dr. Linda, Medical Coordinator, ReliefInternational

Cautain, Jean-Francois, Programme Coordinator,EC



Combes, Jerome, Head of Mission, ACF

Klak, Dr. G. Dastagir, Health Educator Officer,CARE

De Berry, Jo, Adviser, Save the Children/US(SC/US)

Fahim, A., Director International Relations, MoPH

Fleerachers, Yon, Epidemiologist, WHO

Hearne, Nancy, Programme Coordinator, CatholicRelief Services (CRS)

Huff-Rousselle, Peter, Country Representative,UNFPA

Jaberkhil, Dr. Zahir, Programme Support andLiaison Manager, Save the Children/UK (SC/UK)

Jain, Valli, M & C Coordinator, Hope Worldwide

Karisson, Marie, Programme Manager, MedAir

Mahaveer, Regional Administrator, HopeWorldwide

Mahmood, Fund Manager, Hope Worldwide

Mindling, Tim, Deputy Executive Director, IAM

Najla, Dr., Health Officer, SC/US

Naweed, Zholina, Women’s Activities Facilitator,CARE

Ouvry, Arian, Adviser, DFID

Ralf, Donal, Office Manager, CRS

Salama, Peter, Head of Health and Nutrition,UNICEF

Tournieroux, Marie Laure, Project Coordinator,AMI

Van Der Wolff, Robert, Liaison Officer, COROAIW

Wilder, Andrew, Director, AREU

Young, Nigel, Country Manager, Merlin

Site Visits

Basic Health Centre, Batikot District (Jalalabad)

Ghani Khel Rural Hospital (Jalalabad)

Ibn Sina MCH Clinic (Jalalabad)

University Hospital (Jalalabad)

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Bibliography

The Basic Health Services Package for Afghanistan– Second Draft, May 2002

Auxila P., Guiollaume F.D., Schutt P., Pierre L.G.,Cruz E. Lessons learned in subcontracts grantsmanagement – experiences of the Haiti HealthSystem – 2004 project. Management Sciences forHealth.

Benjamin J. Post-Taliban Afghanistan: changedprospects for women? A study on the situation ofwomen and girls in Afghanistan. UN Coordinator’sOffice, Afghanistan. February 2002.

Dalil S., Fritzler M., Ionete D., McIntosh N., O’HeirJ., Stephenson P. Assessment of services andhuman resource needs for the development ofthe Safe Motherhood Initiative in Afghanistan.24 March to 2 May 2002. UNICEF, May 2002.

Duffield M., Gossman P., Leader N. Review of theStrategic Framework for Afghanistan. AREU 2001.

Giradet E., Walter J., eds. Afghanistan – Essentialfield guides to humanitarian and conflict zones.Geneva and Dublin, 1998.

Health Net International. Mrasta. 4:12, April-September 2000.

ICRC. ICRC in Afghanistan – statistics up to May2002.

ICRC. ICRC orthopaedic programme in Afghanistan.January 2002.

Appendix B

Immediate and Transitional Assistance Programmefor the Afghan People – 2002.

Joint Donor Mission to Afghanistan on the Health,Nutrition and Population Sector. Aide-Memoire.May 23, 2002.

Ministry of Public Health. National Health Policy– rehabilitation and reconstruction of health sectorin Afghanistan. February 2002.

Ministry of Public Health. Report of the NationalHealth Sector Planning Workshop,16-19 March, 2002.

MSF. MSF activities in Afghanistan. 6 May 2002.

National Development Framework. Draft forconsultation. April 2002.

Schenkenberg van Mierop E. NGO Coordinationand some other relevant issues in the context ofAfghanistan from an NGO perspective. 9 April2002.

Stockton N. Strategic Coordination in Afghanistanin April 2002. AREU. 2002

Their, A. The Loya Jirga: One small step forward.ICG Report. May 2002.

WHO. Antimalaria drugs for management ofuncomplicated and severe malaria in Afghanistanand refugee camps in neighbouring Pakistan andIraq.

WHO. Health Sector Coordination Report –Afghanistan. Various weekly periods. 2002.



Abbreviations and Acronyms

AACA Afghan Assistance Coordination Authority

ACBAR Agency Coordinating Body for Afghan Relief

ACF Action Contre la Faim

ADB Asian Development Bank

AIMS Afghanistan Information Management Service

AMI Aide Medicale International

AREA Agency for Rehabilitation and Energy Conservation in Afghanistan

AREU Afghanistan Research and Evaluation Unit

CDAP Comprehensive Disabled Afghans Programme

CDC US Centres for Disease Control and Prevention

CHA Coordination of Humanitarian Assistance

CHW Community health worker

CRS Catholic Relief Services

DFID Department for International Development (U.K.)

DOTS Directly Observed Therapy Short-Course

EC European Commission

ECHO European Commission Humanitarian Aid Office

ENT Ear, nose and throat (specialist)

EPI Expanded Programme on Immunisation

EU European Union

GAA German Agro Action

HIS Health information systems

HNI Health Net International

IA Interim Administration

IAM International Assistance Mission

ICRC International Committee of the Red Cross

IDP Internally displaced person

IMC International Medical Corps

IMCI Integrated Management of Childhood Illnesses

IOM International Organisation for Migration

Appendix C

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JDM Joint donor mission

MCI Mercy Corps International

MCH Maternal and child health

MDM Médecins du Monde

MoPH Ministry of Public Health

MRCA Medical Refresher Centre for Afghans

MSF Médecins Sans Frontières

MSH Management Sciences for Health

NAC Norwegian Afghanistan Committee

NCA Norwegian Church Aid

NDF National Development Framework

NGO Non-governmental organisation

OFDA Office of Foreign Disaster Assistance (U.S.)

PHC Primary health care

PPA Performance-based partnership agreements

SC/US Save the Children/U.S.

SC/UK Save the Children/U.K.

SCA Swedish Committee for Afghanistan

SMI Safe Motherhood Initiative

SP Sulfadoxine/pyrimethamine

TB Tuberculosis

TBA Traditional birth attendants

TDH Terre des Hommes

UN United Nations

UNDP United Nations Development Programme

UNFPA United Nations Population Fund

UNHCR United Nations High Commisioner for Refugees

UNICEF United Nations Children’s Fund

UNOCHA United Nations Office for the Coordination of Humanitarian Assistance toAfghanistan

USAID United States Agency for International Development

WB World Bank

WHO World Health Organisation



A Review of the Strategic Framework for Afghanistan, by Mark Duffield, Patricia Gossman andNichloas Leader

Strategic Coordination in Afghanistan in April 2002, by Nicholas Stockton

Addressing Livelihoods in Afghanistan, by Adam Pain and Sue Lautze

The A to Z Guide to Afghanistan Assistance

All AREU publications can be downloaded from its Web site at www.areu.org.pk . Hard copies areavailable by contacting the AREU office in Islamabad: phone: +92 / (0) 51 227-7260.fax: +92 / (0) 51 282-5099 email: [email protected].

Recent Publications by the AREU

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afghanistan research and evaluation unit - welcome to the united

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