Rebuilding health services in post-Taliban Afghanistan

Afghanistan’s health services were left in chaos after years of conflict. Neither the public nor private sectors could function effectively. There was a severe shortage of health staff, and infrastructure was either grossly inadequate or absent. What progress has been made in the past five years to reinstate effective health service delivery?

Across the country health services were either destroyed or in a severe state of disrepair. The ratio of basic health centres to population was anywhere from 1 in 40,000 in central Afghanistan to 1 in 200,000 in the south. Health staff were in short supply and health care was mostly being provided by non-governmental organisations (NGOs). The level and quality of health care delivery varied widely and a clearly defined health policy was non-existent.

In 2002, the Ministry of Public Health and major donors developed the Basic Package of Health Services, providing guidelines for the reconstruction of infrastructure and for staffing. Although both were tentative, the government and NGOs agreed to adopt a public-private design for service delivery which saw the Ministry of Public Health commission and direct while private NGOs delivered the services.

A briefing paper from the Afghanistan Research and Evaluation Unit series explores some of the challenges and attempts to identify the steps that may be needed to help the health sector develop into a respected branch of the government. The paper reports that the Ministry of Public Health has made substantial progress in making the Basic Package of Health Services accessible to most people. The paper makes a number of findings, including the following: 

• There have been significant improvements in quality of care from 2004 to 2005, and from 2005 to 2006. The number of outpatient visits, antenatal care and TB case detection rates have increased substantially.
• The establishment of a Grants and Contracts Management Unit has enabled the Ministry to boost its competency in managing contracts, a critical component of its collaborations with major donors and the NGOs, which have led successfully to a functional health sector.
• Funding of the health sector is currently at a reasonable level yet the country is likely to remain highly reliant on foreign funding for many years and may need more funds for expansion.
• Contracting for service delivery with the NGOs and with three Ministry of Public Health Strengthening Mechanism provinces has been successful.
• Competition for contracts has been strong and notably, a significant proportion of the funds have been awarded to Afghan NGOs set up post 2001 to deliver health services.

If the Ministry of Health can maintain progress in the health sector, it will make a substantial contribution to stabilising the country’s political situation. However, there are a number of significant challenges ahead.

The study recommends that:

• The Ministry needs to develop a good communications strategy to ensure that the public and officials are aware of this sector’s achievements to date, partly to ensure ongoing funding.
• Donors should try to ensure ongoing and predictable funding for the health sector.
• The Ministry and its partners must work to strengthen the Provincial Health Offices’ management capacity so that they are able to execute their responsibilities for managing public health.
• The Ministry should seek to improve the system of contracting by taking the best characteristics from all of the contracting mechanisms.

More recent studies seem to confirm the successes of the health system described in this report. A recent household survey, covering more than 8,000 households throughout Afghanistan, conducted by the independent evaluation team from the Johns Hopkins Bloomberg School of Public Health (USA) and the Indian Institute of Healtlh Management Research, found impressive reductions of more than 20 percent during this decade in infant mortality and child (under five years old) mortality rates. Although many factors might have contributed to these impressive achievements, substantial increases in the proportion of children completing their primary series of vaccinations (now over 70 percent), and in the proportion of women in rural areas having a trained health professional assist with their last delivery (up from six percent to 18.9 percent), accompanied by overall higher attendance rates at primary health clinics have undoubtedly contributed.

Source(s):
‘Afghanistan’s Health System Since 2001: Condition Improved, Prognosis Cautiously Optimistic’, Afghanistan Research and Evaluation Unit Briefing Paper Series, by Ronald Waldman, Lesley Strong and Abdul Wali, 2006 Full document.

Funded by: Afghanistan Research and Evaluation Unit

id21 Research Highlight: 6 August 2007

Further Information:
Ronald Waldman
Program on Forced Migration and Health
Mailman School of Public Health
Columbia University
60 Haven Ave. B-4
New York, NY 10032
US

Tel: +1 202 460 2341
Contact the contributor: rw178@columbia.edu

Afghanistan Research and Evaluation Unit

Other related links:
'NGOs take on health services in Afghanistan'

'The benefits contracting health services in Afghanistan'

'Controlling malaria in post-war Afghanistan'

'Obstacle course – constraints to scaling up health interventions for the poor'

'Rebuilding Afghanistan's health service is hampered by insecurity and lack of funds', The Lancet, by Klaus Morales, 19 November 2005

'A time-seried analysis of health service delivery in Afghanistan', UK Department for International Development Health Systems Resource Centre case study report, by Egbert Sondorp, 2005 (PDF)

'New study finds marked improvements in Afghanistan's health sector', ReliefWeb, 26 April 2007