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Afghanistan Research and Evaluation Unit
Issues Paper Series
The Public Health System in
Afghanistan:
Current Issues
Ronald Waldman
Homaira 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 activities
evaluated. The views and opinions expressed in this report do not necessarily reflect the views of the
AREU.
About the Authors
Ronald Waldman, M.D. M.P.H., is Director of the Programme on Forced Migration and Health, and
Professor of Clinical Public Health at the Mailman School of Public Health of Columbia University.
He is a medical epidemiologist and specialist in child health in developing countries, with extensive
experience working in complex emergencies in Somalia, Rwanda, Northern Iraq, Bosnia and Albania.
Dr. Waldman began his career as a volunteer with the World Health Organisation (WHO) in Bangladesh
during the smallpox eradication programme. He subsequently worked at the U.S. Centres for Disease
Control and Prevention for more than 20 years, where he directed technical support activities for
the Combating Childhood Communicable Diseases project and initiated studies of the epidemiology
of 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. Waldman
is currently the chairman of the International Health Section of the American Public Health Association
and serves in an advisory capacity to a number of international, non-governmental organisations
(NGOs).
Homaira Hanif, M.H.S., an Afghan-American, is a recent graduate of the Johns Hopkins School of
Public Health. The thesis for her Masters in Health Science was on measuring maternal mortality in
Afghanistan. Previously, she worked for Save the Children (US) providing technical and research
support to health projects in refugee/IDP camps in Pakistan and Afghanistan.
About the Afghanistan Research and
Evaluation Unit (AREU)
The Afghanistan Research and Evaluation Unit (AREU) is an independent research institution that
conducts and facilitates quality, action-oriented research and analysis to inform policy, improve
practice and increase the impact of humanitarian and development programmes in Afghanistan. It
was established by the assistance community working in Afghanistan and has a management board
with 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 of
Afghans. 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 its
findings 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 governments
of the Netherlands and Switzerland. Funding for this study was provided by the European Commission
Humanitarian 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
Blank
Executive Summary
Afghanistan's health system is in a state of near-
total disrepair. Standard health indices, including
the infant mortality rate, the childhood mortality
rate and the maternal mortality ratio, are among
the worst in the world. As the new interim
government re-establishes and slowly strengthens
social services, it finds itself facing a multitude
of technical, managerial and operational problems
that need to be clarified before they can be
solved. This report outlines the major issues
currently facing the public health sector, discusses
the roles of government, United Nations (UN)
agencies, donors, and non-governmental
organisations (NGOs), and makes recommendations
for how some of the more pressing problems might
be resolved.
Among the more glaring problems that continue
to affect the ability of the Transitional
Administration of Afghanistan to bring about rapid
and lasting improvements in the health status of
its population are:
a grossly deficient, even absent,
infrastructure;
a health system that is top-heavy with doctors
who are not trained to deal with priority,
community-level problems, and who lack
public health expertise;
poorly distributed resources;
health care delivered on a project basis by
many distinct, relatively uncoordinated service
providers, as opposed to health care delivered
in accordance with a clear and coherent
national health policy; and
lack of practical, useful and coordinated
information systems for management decision-
making.
Despite these problems, there are positive factors
that may allow the government and its partners
to make reasonably rapid progress. These include
a relatively high level of government commitment,
donor interest (at least for the present), technical
and financial assistance from the UN, a strong
and committed community of NGOs and a (limited)
record of successful implementation of public
health programmes in the form of mass
poliomyelitis and measles vaccination campaigns.
An April 2002 Joint Donor Mission (JDM) to
Afghanistan considered options for re-establishing
and strengthening the country’s public health
services. Its principal recommendations were to
develop a Basic Health Services Package that
would form the essential content of the health
system and to manage the delivery of those basic
services through the development of performance-
based, contractual agreements with NGOs.
The Basic Health Services Package, currently
under development by the Ministry of Public
Health (MoPH) and its advisers, consists of seven
major 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 proposed
package had not yet been calculated. In addition,
there are several outstanding issues regarding
prioritisation of the services in the package that
should be explored further. For example, though
mental health and disabilities are important
sources of morbidity and are deserving of the
attention of the public health community, they
require a relatively high degree of specialisation
for intervention and make a small contribution
to excess preventable mortality; they could, for
these reasons, be considered as secondary
priorities. Other issues include “vertical” versus
“horizontal” programmes, the level of
implementation of various interventions and the
need to pay adequate attention to particularly
vulnerable populations.
Whatever the final composition of the Basic Health
Services Package, there are a number of activities
that are common to all of the proposed
interventions and services. These include health
education, 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 advantages
and disadvantages are reviewed, and
recommendations are made in regard to their
eventual implementation. The implications of
these PPAs for each of the major actors – the
Ministry of Public Health (MoPH), the donors, the
UN agencies involved in health and the NGOs –
are detailed.
Although it will be quite difficult to make rapid
progress, this report concludes that there is reason
to be cautiously optimistic about the future of
Afghanistan's public health system and its ability
to improve the health status of its grossly
underserved population. The key elements for
a successful public health programme in this post-
conflict environment include the establishment
of realistic goals and objectives, the careful
prioritisation of services and activities and the
development of efficient and effective
management and information systems that allow
for the close monitoring of progress – or lack of
it – at every level, from the community through
to secondary and tertiary care facilities. But
one can only be optimistic if the most important
prerequisites of all – a stable government, peace
and security – are assured.
Recommendations
The following recommendations on general issues of basic health policy and the content and
management of the Basic Health Services Package are derived from the many interviews conducted
for this report; several are already being implemented:
General Recommendations
1. 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 all
actors 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 each
of the major groups of actors for health (MoPH, UN, NGOs and private practitioners) in the
months following the next JDM to exchange information and to ensure the investment of all
relevant groups.
Recommendations on Content
3. 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 health
and disability services, and develop a schedule for phasing in its components, taking into
account the financial, technical and operational realities of the current situation.
4. Following the completion of appropriate studies, clear policy guidelines should be developed
and enforced for the treatments of choice for pneumonia, malaria and malnutrition.
5. Primary care services should be “pushed down” to the community level.
6. The needs of highly vulnerable populations, particularly returnees, the internally displaced
and conflict-and-drought-affected populations, should not be ignored.
Recommendations on Management
7. NGOs should be more involved in the next JDM and full participation of the donor community
should be assured.
8. A representative delegation of the public health community in Afghanistan should be 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 behaviours
and household expenditures on health.
Issues Paper Series
Afghanistan Research and Evaluation Unit (AREU)ii
1These figures, cited in the Aide-Memoire of the JDM to Afghanistan on the Health, Nutrition, and Population Sector (9 April
2002 draft), are attributed to the United Nations Children’s Fund (UNICEF) and the World Health Organisation (WHO). The life
expectancy figure is from the National Health Policy, February 2002. There is widespread agreement that available nationwide
health statistics in Afghanistan are inaccurate, and the health status of the population, by all commonly used statistical indicators,
is abysmal.
2The international assistance community, to the extent that it is a “community,” includes multilateral and bilateral donors, UN
agencies and the large and diverse group of national and international NGOs. Among these NGOs are those who have been
working in Afghanistan for years and whose approach to assistance is for the most part “developmental,” those who arrived
during the post-September 2001 “emergency period” and are primarily “relief” oriented, and combinations of the two.
3The JDM was led by the World Bank (WB) and the World Health Organisation (WHO). Members of the team included representatives
from Department for International Development (DFID), the European Union (EU), the United States Agency for International
Development (USAID), the Asian Development Bank (ADB), UNICEF and the United Nations Population Fund (UNFPA).
When one considers the most frequently cited
health statistics in Afghanistan – infant mortality
(165/1000 live births/year), maternal mortality
(1700/100,000 live births/year) and life
expectancy at birth (46 years) – it would be easy
to conclude that, for the future, the only way is
up.1 However, without a carefully designed and
expertly managed public health system, an ability
to identify, address and monitor the most common
health problems of the population, and a way to
ensure the quality of both preventive and curative
services, it is possible that Afghanistan will be
relegated to the bottom of the UNDP Human
Development Index for years to come. The
challenges facing the re-development of
Afghanistan’s health system are well known and
have been frequently discussed in international
circles during the past six months. This report
focuses specifically on the elements of the health
sector, as observed in May-June 2002, that require
additional consideration and short- to-medium-
term action to establish the conditions for effective
health system management and health care
delivery.
At the time this issues paper was conceived by
the Afghanistan Research and Evaluation Unit
(AREU), there was great concern that the
international assistance community would adopt
an urban-centred, tertiary care approach to health
sector re-development.2 Therefore, the key term
of reference for the team was, “to analyse the
overall approaches being adopted by these
agencies, particularly in relation to their adoption
of the public health model versus more curative
approaches.”
Shortly after their arrival, team members
determined that, for the most part, this concern
was unfounded. The draft Aide-Memoire of the
Joint Donor Mission (JDM) to Afghanistan on the
Health, Nutrition and Population Sector was the
dominant document under discussion, and it had
a clear and forceful public health orientation.3
The Aide-Memoire built upon the classical primary
health care orientation of the National Health
Policy, written in February 2002. After reviewing
the principle features of the health system as it
existed in Afghanistan in early 2002, the Aide-
Memoire strongly urged the redistribution of
health services to provide equitable access in
underserved areas, the development of a
standardised package of basic health services
that would form the core of health care delivery
in all primary health care facilities (see Section
II), and the development of a set of measurable
indicators that would allow for the regular
monitoring of progress toward clearly defined
health sector objectives. All these are standard
features of the public health approach.
The most striking feature of the Aide-Memoire is
its recognition of the limitations of the MoPH’s
capacity to deliver health services to its entire
population and the inefficiency of a civil-service-
based health system in the form of its
recommendation that a strong partnership be
developed between the MoPH and the private
sector. The pillar of this partnership would be
performance-based partnership agreements (PPAs)
under which the government would contract with
the private sector (local and/or international
NGOs and/or other private sector entities) for
the delivery of specified health services to the
population (see Section III).
In May 2002, the PPA proposal had been endorsed
in principle by the Afghan Assistance Coordination
I. Introduction
Afghanistan Research and Evaluation Unit (AREU) 1
The Public Health System in Afghanistan: Current Issues
Authority (AACA) and by the MoPH, but had not
yet been developed in detail nor adequately
presented to the NGO community. The Aide-
Memoire is honest and clear about the problems
– potential and real – facing effective
implementation of its proposals, but a proposed
second JDM has been postponed until mid-July.
In the interim, both enthusiasm and concern have
been voiced by members of the NGO community.
One of the roles of the AREU team was, by
default, to try to discuss the salient features of
the proposal with the NGO community and others
in Kabul and in the eastern region, and to elicit
their reaction. Toward the end of this
consultation, at the request
of some of the NGOs, the
research team held a
meeting to review the
important features of the
proposed PPAs, and to
discuss them in light of
experience gained in other
post-conflict settings. In
addition, a well-attended
formal debriefing for
representatives of the
MoPH, the donor
community, the UN agencies
and the NGOs was held to
discuss issues and findings.
This report presents these
findings and observations
based on the proposal of
the JDM, the content of the
current Basic Health
Services Package, a review
of the plans and
programmes of a number of
donors, UN agencies and
NGOs, and other important
aspects of the health care
system in Afghanistan.
The research for this report
was limited in scope and
depth by a number of
important constraints.
First, time did not allow the
team to contact as many
people as anticipated.
Although a large sampling
of respondents from
governments, donors, UN
agencies and NGOs was interviewed, important
and influential commentators may have been
missed. A list of persons contacted can be found
in Appendix A. Second, travel in Afghanistan
was quite difficult during the time of our research.
Access to many areas was by plane and required
a lengthy stay-over in Peshawar or in Islamabad,
Pakistan. For this reason, a four-day visit to
Jalalabad, of which most of two days were spent
on the unpaved road connecting that city with
Kabul, was the only field trip undertaken.
Although Nangarhar (the province in which
Jalalabad is located) is one of the relatively
economically advantaged and, in terms of health
Issues Paper Series
Afghanistan Research and Evaluation Unit (AREU)2
Courtesy of WHO
care, one of the better served areas of
Afghanistan, and can therefore not be said to be
representative of the rest of the country, the trip
was informative and enlightening in many respects.
Third, the scope of work was broad. The team
found most issues concerning food security and
food assistance to be beyond our capacity and so
concentrated on the management and delivery
of preventive and curative health services
including, to a moderate degree, nutrition
supplementation programmes. Finally, the rapid
turnover of international staff in most international
agencies (UN and non-governmental) meant that
in many cases those to whom we spoke were
relative newcomers to Afghanistan (although their
agencies may have been in country for many
years), and could not give information with the
historical perspective that might have lent
additional depth to this report.
In spite of these limitations, this report covers
the main issues facing the re-development of the
health sector in Afghanistan. We have divided
the report into two main sections – issues
concerning the proposed content of the health
system, and issues affecting its management.
Though those who are currently working in
Afghanistan are far more familiar with these issues
and their potential consequences, this report
aims to provide a synthesis of the information
provided by those we interviewed, through the
direct observations made in hospitals, basic health
centres and maternal/child health (MCH) centres,
and by consulting other documents and texts
before and during the trip to Afghanistan. The
goal of the team was to produce a report to both
serve as a reference and help organise the current
issues for those currently working in the health
sector, and provide a short, digestible orientation
for those who have yet to arrive. Although it
may seem bold, where we feel comfortable doing
so, we make recommendations for future action.
This report is intended to be a positive
commentary on what has been done to date in
the short time that the Interim Administration
(IA) has governed Afghanistan. These are dynamic
and turbulent times in Afghanistan. The way
forward may frequently seem obscure and fraught
with insurmountable obstacles, natural and man-
made. We are cautiously optimistic about the
future of the health sector in Afghanistan, always
on the condition that: 1) there be peace
throughout the country; and 2) there be a stable
and legitimate government capable of setting
sound technical and managerial policies and
commanding the respect of those who will be
responsible for implementing them.
Afghanistan Research and Evaluation Unit (AREU) 3
The Public Health System in Afghanistan: Current Issues
Content
The recent JDM recommended a number of next
steps to the MoPH and its local partners. Not
surprisingly, because a standardised set of services
is one of the hallmarks of the public health
approach, one of the earliest of these steps was
the definition of the essential package of services
to be made available throughout the public health
system in Afghanistan. This basic package would
be responsive to epidemiological imperatives of
the country, addressing those problems that are
indicated by available data or by consensus opinion
to impose the greatest burden on the population
in terms of morbidity and mortality. But
epidemiological criteria were not the only ones
to be applied. The basic package would contain
only those health problems for which safe and
effective interventions are currently available.
It would seek an equitable balance between
interventions that are cost-effective and those
that are important to a large segment of the
population (where there are differences between
the two). Finally, it would balance the quality
of health services with the extent to which those
services can be offered at the most peripheral
areas of the system – that is, low-cost, basic
services for all, versus more expensive, more
sophisticated services for a relative few. In order
to help define the package, an Advisory Committee
to the MoPH has been formed. The Committee
consists of the MoPH, the three UN agencies
involved in health (WHO, UNICEF, UNFPA), and
Management Sciences for Health (MSH), which is
providing technical assistance to the MoPH in the
areas of policy and management and which will
soon be initiating a grants programme to NGOs
for relevant health programmes and
representatives 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
4As detailed in the May 2002 document, A Basic Health Services Package for Afghanistan – Second Draft, Document for Discussion.
Issues Paper Series
Afghanistan Research and Evaluation Unit (AREU)4
in its content and addresses many (but by no
means all) of the major public health problems
of Afghanistan. A detailed and well-reasoned
discussion of each of the individual items, with
appropriate questions regarding the extent to
which they can be implemented, is presented in
the draft document (e.g., which antigens should
be included in the EPI
and what degree of
specialisation is required
for the implementation
of mental health
problems). A large part
of the document is
devoted to the delivery
of the different
components of the essential package at different
levels of the health system – community, health
centre and hospital.
The draft report also discusses the many
constraints to the implementation of the proposed
package, essentially concluding that, “…although
each one of the components listed in the basic
package proposed can be regarded as modest,
providing the whole range of services has proven
too big a challenge for most developing countries.”
As confirmed by the MoPH, it will also prove too
big a challenge for Afghanistan in its current form.
At this early stage of redevelopment of the Afghan
health system, the adoption of modest goals and
objectives, rigorous prioritisation of interventions
and the strict discipline required to maintain a
focus on a quite narrow range of activities are
essential. The health status of the Afghan
population at this time is quite poor and it is a
sad but true reality that there are no quick fixes.
Much can be done in a short time, but it is a near
certainty that the health status of the population
will remain poor for years to come. The bitter
pill that must be swallowed by all those working
in the Afghanistan health sector is that even if
peace and political stability are achieved, the
legacy of 20 years of war and political instability
that resulted in the destruction of the health
infrastructure of the county, and the failure to
develop an adequate cadre of technically
competent health workers will be present for the
foreseeable future. The short-term and mid-term
outcomes of the numerous activities being
conducted in the health sector today, even if
they could be highly coordinated, delivered in a
most efficient manner and distributed equitably
throughout the country, can lead only to a
relatively better situation, but not to a good one.
A concerted effort over a long period of time is
what will be required to bring down mortality
rates in a sustainable manner and return the
health of the people of Afghanistan to the state
of health to which they have every right.
For a fuller discussion of
the issues involved in
the implementation of
an essential package of
services, the official
document, when it is
completed, should be
consulted. Here we
highlight a few of the major considerations that
should be taken into account for each of the
technical programmes currently under
consideration, and for the delivery of the proposed
basic package as a whole.
Maternal and Newborn Health
The maternal mortality ratio in Afghanistan, while
undetermined, is believed to be among the
highest, if not the highest, in the world. The
most quoted figure is 1700 maternal deaths per
100,000 live births per year. A research study
A concerted effort over a long period of time
is what will be required to bring down
mortality rates in a sustainable manner and
return the health of the people of Afghanistan
to the state of health to which they have
every right.
Afghanistan Research and Evaluation Unit (AREU) 5
The Public Health System in Afghanistan: Current Issues
John Isaac for UNICEF
aimed at getting a more accurate figure for
maternal mortality is currently being implemented
by a team from the U.S. Centres for Disease
Control and Prevention (CDC). The broad
application of the Safe Motherhood Initiative (SMI)
of the WHO and UNICEF, with particular emphasis
on the provision of emergency obstetrical care,
is a proven intervention that could, in time, bring
about an important reduction in maternal
mortality.
UNICEF recently conducted an assessment of the
resource needs required to implement the SMI in
Afghanistan.5 The team made several
recommendations that are generally applicable
to all of the public health programmes that will
be included in the Basic Package of Health
Services. Specifically, they suggested that a
strong and immediate emphasis be placed on the
training of intermediate and lower-level health
workers, that technical and financial support be
given to NGOs working on the SMI, and that MoPH
capacity in the area of maternal and newborn
health be strengthened.
In the medium term, it is interesting that the
team suggested that the principal objective of
the SMI in Afghanistan be to increase the
proportion of births attended by skilled health
personnel (trained and qualified traditional birth
attendants (TBAs), auxiliary midwives, midwives
or female physicians). In order to achieve this
objective, they urged the development, by
consensus of the actors in the Afghanistan health
system, of a National Reproductive Health Policy
with standards and guidelines for the delivery of
a minimum set of essential reproductive health
services. The implementation of these services
should be closely and carefully monitored by the
development and inclusion of a set of specific
indicators in the routine health information
system, complemented by periodic, special
surveys.
The team made recommendations regarding the
provision of antenatal care. These included
tetanus toxoid immunisation, supplementation
of the diet of pregnant women with iron and folic
acid and malaria prevention (but, notably, no
mention is made of presumptive treatment for
malaria twice during pregnancy in areas and at
times of high incidence – an intervention that has
proven to be inexpensive and effective). The
team also discussed health education about the
danger signs of pregnancy, delivery in the presence
of a skilled birth attendant, and emphasis on
immediate breastfeeding, including colostrum
and exclusive breastfeeding for six months.
But perhaps the most important of the
recommendations, especially in the Afghanistan
context, is that emergency obstetrical services
be extended through the training and deployment
of appropriate staff. TBAs trained to recognise
obstetrical complications, close linkages between
TBAs and local health facilities and regular
monitoring of TBA performance is crucial to the
success of the SMI initiative. Equally important
is the observation that Afghanistan currently has
too 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 be
offered is not specifically discussed in the SMI
report. Maternal deaths from obstetrical
complications are not predictable and can require
sophisticated care including parenteral antibiotics,
blood transfusions and/or surgical delivery
(Cesarean section). Because of the difficulties
of physically accessing health facilities, women
living in remote areas may not be able to take
advantage of these services even if they are
available at the hospital level. It is critical, if
maternal mortality is to be reduced, that TBAs
and other staff working in the community and at
the basic health centres be trained to recognise
the warning signs of complicated delivery, and
that they be able to quickly refer the patient to
a level of care where comprehensive obstetrical
care is available. Strong consideration must be
given to training non-physicians in appropriate
life-saving obstetrical techniques, including
surgery, as is being done with considerable success
in a few other countries. It should also be
mentioned that it is not enough to have
community-level recognition of impending
problems and facility-based competence to deal
with those problems. Transport between the two
needs to be assured, and this poses a huge problem
in Afghanistan.
5Dalil S., Fritzler M., Ionete D., McIntosh N., O’Heir J., Stephenson P. Assessment of Services and Human Resource Needs for
the Development of the Safe Motherhood Initiative in Afghanistan. Conducted by JHPIEGO for UNICEF/Kabul. 2 May 2002.
Issues Paper Series
Afghanistan Research and Evaluation Unit (AREU)6
The issue of “pushing down” services to the most
peripheral level of care and into the hands of
non-physicians is discussed further below. It is
critical to the effective implementation of the
Basic Health Services Package in Afghanistan.
Although the Basic Health Services Package groups
maternal health and newborn care, there is
relatively little emphasis on the latter. Of course,
ensuring tetanus toxoid vaccination during
pregnancy, together with the other elements of
the SMI, would go far to improving newborn
survival rates. Proper initiation
and maintenance of
breastfeeding is of unparalleled
importance. However, in any
case, a high proportion of infant
mortality occurs during the
newborn period (see below).
On the other hand, both the
diagnosis and the treatment of
many potentially fatal conditions
of the newborn are difficult,
expensive and beyond the reach
of most health facilities in
Afghanistan. It would not be
inappropriate, at this time, to
concentrate on reducing infant
and child mortality from the
most common causes of illnesses,
and addressing the problems of
the newborn period at a later
date.
Child Health and Immunisation
More than one-fourth of children born in
Afghanistan do not reach their fifth birthday.
This appalling statistic
is due to a variety of
factors, which include:
incorrect household
behaviours (especially
inadequate
breastfeeding);
incorrect treatment of
common, but potentially
life-threatening
illnesses, such as
diarrhoea; little recognition of the early warning
signs of severe respiratory infection and severe
malaria; poor health care-seeking practices;
inadequate health care at the community/basic
health centre levels; and lack of access to health
services.
Nevertheless, Afghanistan has recorded recent
successes in the area of childhood immunisation,
extending polio vaccination widely throughout
the country and making measurable progress
through the implementation of a measles mortality
reduction strategy consisting largely of mass
vaccination campaigns. According to some, it is
unlikely, at the time of this report, that many
Afghan children remain unvaccinated against
polio, and the number of cases detected, even
in light of intensified surveillance, has been
decreasing. According to others, substantial
pockets of unvaccinated children remain.
Nevertheless, it seems likely that important
progress has been made over the last few years.
If one can judge from the experience of other
countries in difficult circumstances, the success
of National Immunisation Days may well eliminate
polio from Afghanistan in the next year or two
and make a major
contribution to the
global eradication
effort. But eradicating
polio will not contribute
to reducing child
mortality, to which this
disabling (and
sometimes fatal) disease
makes a relatively small
contribution. In
contrast, the implementation of the measles
mortality reduction strategy that targets children
from the age of six months in specific geographic
areas, combined with the delivery of vitamin A
supplementation to children less than five years
old, can have a substantial impact, if sustained.
The implementation of the measles mortality
reduction strategy that targets children from
the age of six months in specific geographic
areas, combined with the delivery of vitamin
A supplementation to children less than five
years old, can have a substantial impact, if
sustained.
Afghanistan Research and Evaluation Unit (AREU) 7
Courtesy of WHO
The Public Health System in Afghanistan: Current Issues
These “vertical” campaign-oriented programmes
have shown that, with appropriate guidance and
assistance, the Afghan health system can perform
at a high level. But the ongoing provision of
routine, community-based and facility-based
preventive and curative programmes is, in some
ways, more challenging.
The major causes of childhood mortality in
Afghanistan, in addition to measles, are diarrhoea,
pneumonia and malaria, compounded by
malnutrition. For each safe, effective and cost-
effective treatment can
be made available.
These diseases are the
subjects of the
WHO/UNICEF IMCI
initiative.
The objective of IMCI is
to address the major
causes of childhood
mortality in an integrated, holistic fashion. IMCI
works
1. At the community level to promote
appropriate household behaviours;
2. At the basic health centre level to ensure the
accurate assessment, diagnosis and effective
treatment of potentially life-threatening
diseases;
3. At the hospital level to provide tertiary care
to severe cases; and
4. At the level of the health system to implement
in-service training, regular monitoring and
supervision throughout the health services
and periodic evaluation.
An essential element of IMCI is its training course
for intermediate health workers. Following an
intensive initial study phase during which the key
elements of the IMCI treatment algorithm are
adapted to the national/local context, training
of health workers begins. The training course is
long (13 days) and includes considerable practical
(by-the-bedside) instruction. Experience has
shown that the number of health workers that
can be trained in a short period of time is relatively
small.6
Fortunately, the epidemiological characteristics
of Afghanistan may allow training of health care
workers in the appropriate care of the major
killer diseases of children to proceed more rapidly.
Although health workers trained in IMCI may be
able to provide more effective clinical care, it is
also possible to provide training to address the
most commonly occurring conditions. In
Afghanistan there are
distinct seasons, each
with a characteristic
disease profile.
Diarrhoea and malaria
are primarily diseases of
summer; pneumonia has
a higher incidence in
winter. Until the
adaptation of the
generic IMCI programme can be completed and
until a sufficient number of trainers can be trained,
“vertical,” season-oriented training of clinic-
based health workers and health education
messages appropriate to the time of year should
be developed.
The need for this training (both pre-service and
in-service) is clear. After 20 years of conflict,
Afghanistan has been left with an over-medicalised
corps of health personnel that has not been able
to stay abreast of recent advances in knowledge
and medical practice. A bulletin, circulated by
an NGO currently supporting health care in
Afghanistan, quotes a professor of pediatrics as
saying that “…cotrimoxazole, besides having no
risk, is beneficial in controlling…diarrhoea in
children.” Both of these points are incorrect:
cotrimoxazole, an inexpensive antibiotic, does
have risks and is not effective for the treatment
of diarrhoea in children. Childhood diarrhoeal
deaths have been substantially reduced (by more
than one million per year) in developing countries
by abandoning the use of antibiotics and “intestinal
disinfectants” in favour of even less expensive,
truly without risk, oral rehydration salts. Afghan
health care professionals need to be trained in
Afghan health care professionals need to be
trained in the use of modern, cost-effective
interventions, and these interventions need
to be made available where they will have
the greatest impact: in, or as close as
possible, to the communities where the
diseases occur.
6This is true for most programmes that have large training requirements – the SMI assessment cited above suggests that it would
take 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.
Issues Paper Series
Afghanistan Research and Evaluation Unit (AREU)8
the use of modern, cost-
effective interventions, and
these interventions need to be
made available where they will
have the greatest impact: in,
or as close as possible, to the
communities where the diseases
occur.
Public Nutrition
The interventions specified in
the current draft of the Basic
Health Services Package are
micronutrient supplementation
and the treatment of clinical
malnutrition. The former
presumably means the
administration of vitamin A
capsules to children and
iron/folate tablets to pregnant
women. Vitamin A
supplementation has been
shown to reduce childhood
mortality due to a number of
diseases including diarrhoea and
pneumonia. It has become a
common intervention in tropical
developing countries. In
Afghanistan, vitamin A
supplementation has been
provided, together with polio
vaccines, during the National
Immunisation Days. No studies
of vitamin A levels are
available, but it is assumed,
rather than documented, that
there is a high prevalence of
vitamin A deficiency in children. However, a
nutrition survey in Badghis Province found a
relatively low 2.6% of children with at least one
clinical sign of vitamin A deficiency.7 Other
vitamin deficiencies, including riboflavin deficiency
and vitamin D deficiency (rickets), are at least a
potential problem in Afghanistan, and outbreaks
of vitamin C deficiency (scurvy) have been
documented quite recently. Whether or not
dietary supplementation with these vitamins will
be provided through routine prevention services
7Woodruff 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, that
recognition of the early stages of clinical vitamin A deficiency by relatively untrained workers may not be very reliable.
Afghanistan Research and Evaluation Unit (AREU) 9
at MCH clinics and basic health centres is not
clear.
All women should receive supplements of iron
and folic acid during their pregnancies. This
standard intervention should be routinely initiated
and monitored at MCH clinics and by community
health workers (CHWs) and TBAs at the community
level. Compliance rates vary greatly and studies
should be done to determine the degree to which
Afghan women are supplementing their diets
during pregnancy. The prevalence of anemia in
Ronald Waldman
The Public Health System in Afghanistan: Current Issues
pregnancy should also be determined in different
regions of the country, as anemia is a risk factor
for maternal mortality.
The treatment of clinical malnutrition is not a
straightforward issue. Malnourished children can
be detected through a system of growth monitoring
and promotion when they are brought to a health
facility for other illnesses, or through active,
community-based nutrition surveillance. Many
nutrition supplementation programmes are
currently being supported by UNICEF and
implemented by various NGOs throughout the
country. Most of these detect children who are
less than 80% of the median weight-for-height of
reference populations and provide them with
vitamin-fortified cereals and vegetable oil to take
home (programmes discussed provided two
kilograms for a two-
week period). Although
no one is sure who
actually consumes the
food supplements in the
home, the theory is that
increasing the household
food supply will allow
the child to eat more
and resume normal
growth. Supplementary feeding programmes are
currently being provided in a patchy distribution
in Afghanistan. Their effect is not yet clear and
monitoring and evaluation systems are incomplete.
Although they are based on the detection of acute
malnutrition, a much more important problem in
Afghanistan seems to be very high levels of
stunting, or chronic malnutrition (57.5% according
to the UNICEF/CDC survey in Badghis Province).
Underlying causes undoubtedly include poor
breastfeeding practices and inappropriate
complementary feeding in children under six
months old and during the weaning period. In
other words, although both vitamin
supplementation of healthy children and pregnant
women and the treatment of clinical malnutrition
in children are appropriate elements of the Basic
Health Services Package, the important problem
of chronic under-nutrition will not be adequately
addressed by them. Rather, important behaviour
change interventions in the area of child feeding
also need to be developed. An analysis of stunting
in Afghanistan using the widely-accepted UNICEF
conceptual framework for causes of malnutrition
might be revealing.
Finally, an interesting phenomenon in Afghanistan
is the documentation of relatively high levels of
child mortality in the absence of high levels of
acute malnutrition. This unusual phenomenon
should be investigated and the potential role of
micronutrient deficiencies explored.
Communicable Diseases
Malaria
Malaria is endemic in Afghanistan. As indicated
above, it occurs seasonally, with transmission
from April-November throughout the country.
Although most malaria is due to P. vivax, which
remains sensitive to chloroquine, about 15% is
due to P. falciparum, which is felt to make an
important contribution to child mortality.
P.falciparum in
Afghanistan appears to
be largely resistant to
chloroquine, which
nevertheless remains
the drug of choice.
Resistance to sulfa-
doxine/ pyrimethamine
(SP) has been documen-
ted at low levels and
needs to be carefully monitored.
Research into malaria prevention has been carried
out by HealthNet International (HNI), in
conjunction with the London School of Tropical
Medicine and Hygiene. Demonstrations of the
cultural acceptability of impregnated bed nets
and their effectiveness in blocking the acquisition
of malaria infection have led to large bed net
distribution programmes in parts of the country.
HNI has been involved in the distribution of more
than 450,000 impregnated bed nets to date.
Work is also being done on the effectiveness of
impregnated clothing (chadors), on cattle sponging
and on stocking ponds with the larvicidal fish, or
gambusiae, in an attempt to reduce mosquito
breeding sites.
However effective these technical interventions
may prove to be, malaria control will depend on
the system of health services delivery that is
developed. At present, there appear to be two
systems for dealing with the occurrence of malaria
at village level. In one, community health workers
are taught to recognise the symptoms of malaria,
but they are not allowed to provide treatment –
Issues Paper Series
Afghanistan Research and Evaluation Unit (AREU)10
An interesting phenomenon in Afghanistan
is the documentation of relatively high levels
of child mortality in the absence of high
levels of acute malnutrition. This unusual
phenomenon should be investigated and the
potential role of micronutrient deficiencies
explored.
As is the case with malaria control, the vaccination
campaign and the proposed national micronutrient
fortification programmes mentioned above,
tuberculosis control in Afghanistan will require a
mix of specialised technical expertise and
assistance at the higher levels of the system, and
well-informed strict implementation of national
policies and strategies at the village and health
facility levels. This mix of “vertical” and
“horizontal” programmes is discussed below.
Leishmaniasis
Other specialised programmes, even ones that
are currently being pursued in Afghanistan, are
not included in the Basic Health Services Package.
Leishmaniasis is a serious, but not fatal, disease
that occurs throughout large parts of Afghanistan,
including urban areas. Though treatment is
available, it is quite expensive and would have
to be provided through external funding for the
foreseeable future. HNI is currently supporting
a leishmaniasis clinic in Kabul. WHO is also
involved in disease control activities.
they refer suspect cases to the nearest health
facility where the definitive diagnosis is made by
microscopic examination of a blood smear before
treatment is given.8 In the other, CHWs can
diagnose and provide treatment (chloroquine is
the only anti-malarial currently proposed for use
at the community level in the draft Basic Health
Services Package). There are advantages and
disadvantage to each approach, but given that
that severe P. falciparum malaria can kill within
24 hours, combined with the difficulty that much
of the Afghan population has in
accessing health facilities, a
strong case can be made for
community-level diagnosis and
treatment (see below).
Tuberculosis
Tuberculosis (TB) is generally
considered to be an important
cause of adult mortality in
Afghanistan. Mortality is felt to
be disproportionately high in
women because of their relative
lack of access to care, especially
for chronic conditions such as
TB. A number of agencies,
including WHO, MedAir, German
Medical Service, and Médecins
Sans Frontières (MSF), are
running specialised (vertical)
anti-TB programmes in different
parts of the country. Although the globally
accepted Directly Observed Therapy Short-Course
(DOTS) strategy is widely recommended in
Afghanistan, and has been successful under the
watchful eye of the NGOs in some parts of the
country, it will be a challenge to implement it
widely.9 As with so many disease control
programmes, success depends on accurate
diagnosis of a large proportion of cases, an
adequate and regular supply of effective drugs,
and appropriate action at the community level.
Regular monitoring and periodic evaluation are
indispensable.
8For this system to work effectively, trained laboratory technicians must be available in all health facilities. Although HNI is
undertaking an extensive programme of monitoring and reinforcing diagnostic capability, this is not being done on a national
level. In some areas, the use of newly available, very reliable, rapid diagnostic tests might be considered, although they are,
at this point, relatively expensive.
9DOTS involves a series of activities, ranging from diagnosis through monitoring of the TB situation and evaluation of programme
effectiveness. The main feature of the intervention is the requirement that anti-tuberculosis drugs be taken under the supervision
of someone other than the patient – a relative or community health worker, for example. The purpose of directly observed
therapy is to improve compliance rates.
Afghanistan Research and Evaluation Unit (AREU) 11
The Public Health System in Afghanistan: Current Issues
Courtesy of WHO
Blindness
The International Assistance Mission (IAM) is an
NGO that specialises in eye care. It conducts eye
camps in parts of Afghanistan and provides surgical
procedures, for a fee, in a variety of settings.
The services are clearly necessary and sought
after, but require a high degree of specialisation
that is not apparently compatible with a more
generalised primary health care approach. IAM
is privately funded, to a large degree, by the
Christofel Blinden Mission of Germany, and does
not rely heavily on public resources.
HIV/AIDS
HIV/AIDS control is a subject that must figure in
all discussions of public health. To date, no
formal activities are being conducted in this area,
though some health education, mostly through
mass media, is said to be occurring. The MoPH
has not yet organised
itself to address
HIV/AIDS and no
mention is made of it in
the Basic Health Services
Package in any way.
Yet, Afghanistan is
certainly threatened by
the introduction of the
HIV virus, with so many
people returning from
Iran, Pakistan and other
countries. Recently, reports of the detection of
a number of cases have been circulating.
Afghanistan is in a position to prevent the
widespread transmission of HIV/AIDS in its
population. But to do so it will have to organise
HIV/AIDS prevention activities and begin to
educate people about the modes of transmission.
In a conservative, religious culture where sex is
not openly discussed, broaching the subject must
be done in a sensitive, careful way. The time to
start HIV control activities is now. Information
regarding HIV seroprevalence may be available
through the International Committee of the Red
Cross (ICRC), or other NGOs that are supporting
surgical services (including blood transfusion) in
parts of the country. Screening of blood collected
for transfusion could be done on an anonymous
and unlinked basis. Other opportunities for blood
screening, such as antenatal care clinics, could
also be used to establish a baseline seroprevalence
rate and to monitor changes. Safe blood handling
and transfusion techniques, as well as universal
precautions in clinical settings, could be instituted
in short order and should be.
Other Diseases
Consideration needs to be given to specialised,
vertical disease control programmes that are not
part of the Basic Health Services Package. Other
programmes, including the detection and control
of diseases of epidemic potential, such as bacterial
meningitis, viral hemorrhagic fevers, typhoid
fever and others that are known to pose a threat
in Afghanistan, also need to find a place within
the MoPH.
Mental Health
There is general agreement that mental health
problems are highly prevalent in Afghanistan
today. After twenty years of conflict,
characterised by the
uprooting of millions
people and massive
destruction of private
and public property, and
the total disruption of
the lives of two
generations of Afghans,
this is not surprising.
Several studies have
documented high levels
of depression
characterised by various degrees of loss of
motivation through suicidal ideation. There are
undoubtedly many people in Afghanistan who
would benefit from psychotropic medications.
In fact, the abuse of these sedatives is widely
reported. Opium abuse is also reported to be an
important problem, even among women. In
addition, many people who do not require
medication would benefit from a strong system
of social support through which they could be
helped to cope with the ongoing stresses to which
they are subjected. But the majority of mental
health needs could probably be met by a return
to normal life. Community development activities,
such as the opening of schools, the creation of
income-generating activities and increased security
and stability, would probably alleviate the mental
health problems of the vast majority of Afghans.
As of now, it is not clear what the mental health
interventions of the Basic Health Services Package
would look like. The assessment, diagnosis and
The majority of mental health needs could
probably be met by a return to normal life.
Community development activities, such as
the opening of schools, the creation of
income-generating activities and increased
security and stability, would probably
alleviate the mental health problems of the
vast majority of Afghans.
Issues Paper Series
Afghanistan Research and Evaluation Unit (AREU)12
being, disability services be omitted from the
Basic Health Services Package. Further studies
regarding the appropriate interventions at
different levels of the system and the cost of
providing these services should be undertaken
and the possibility of phasing in these services at
a later date considered. In the meantime, ICRC
and the other agencies addressing the problem
of disability should be encouraged to continue
their activities, to expand them to rural hospitals
if possible, and to help the MoPH develop a long-
term strategy for dealing with this important
problem.
Essential Drugs
The selection of a list of essential drugs is always
controversial. The medicines needed for the
implementation of the Basic Package of Health
Services are fairly straightforward. Choices need
to be made with regard to antibiotics, antimalarials
and antituberculosis medications as a function of
the epidemiological characteristics of the diseases,
available finances and cultural acceptability.
More difficult, though, is the inclusion of drugs
that do not correspond to the interventions of
the Basic Health Services Package. The provision
Afghanistan Research and Evaluation Unit (AREU) 13
John Isaac for UNICEF
treatment of patients requiring prescription
medications is definitely too specialised for
implementation at the community level and
probably surpasses the capacity of most basic
health centres. At best, one could recommend
that patients in need of specialised care be
referred to higher levels of the system. Although
mental health problems were mentioned
frequently at the National Health Sector Planning
Workshop in March, it is not clear that there is
a safe and effective set of interventions currently
available to deal with the problem through a
primary health care approach. NGOs currently
engaged in psychosocial activities should make
reports of their accomplishments public, and
technical expertise should be sought for the design
of mental health programmes that make sense in
the Afghan context.
Disability
It is well-known that physical disability that
interferes with people’s abilities to earn money
and to take care of themselves and their families
is an important problem in Afghanistan. War-
related disabilities, including mine injuries, have
been important, but other causes of disability,
including cerebral palsy and polio, are reported
by some to outnumber these by as much as four
to one. One of the most prominent agencies
currently working in the area of disabilities that
we were able to meet with in preparing this report
is the ICRC, which has been in Afghanistan since
1986. ICRC works primarily with handicapped
war survivors, of which it estimates there are
about 200,000. UNDP’s Comprehensive Disabled
Afghans Programmes (CDAP), whose future is now
uncertain, covered a wider range of disabilities
than the ICRC. SERVE, the Sandy Gall Afghanistan
Appeal, and a number of other agencies are also
working to provide rehabilitation services to those
in need.
It is not clear how disabilities will be included in
the Basic Package of Services. ICRC has expressed
a desire to have the manufacture of prosthetic
and other devices decentralised from its six
centres to more peripheral locations.
Physiotherapy services could also be provided at
peripheral facilities of the health system but, as
is the case for mental health services, a certain
degree of expertise that would surpass the capacity
of most basic health centres might be necessary.
It seems reasonable to suggest that, for the time
The Public Health System in Afghanistan: Current Issues
of these other essential drugs is of paramount
importance if the public health system is to retain
credibility and earn the trust of the public. But
it is important to choose only those medications
that can be safely and effectively used at the
levels of the system for which they are designated.
For the time being, 18 items are listed for use
at the community level, ranging from condoms
and gentian violet to cotrimoxazole and anti-
tuberculosis drugs. Thirty-four items are listed
for the basic health centres and 65 for the rural
hospitals, including those used for anesthesia,
the treatment of severe malaria and other tertiary
care problems.
In summary, the Basic Health Services Package
is a fundamental part of the public health approach
to health system development in a post-conflict
setting. The package currently being debated in
Afghanistan includes a number of interventions
that are of indisputable priority, but it may be
quite ambitious for immediate implementation.
Some of the interventions that are currently
included should be reconsidered. The MoPH’s
expressed preference for phasing-in the package
should be accepted and a schedule for this
progressive introduction of services should be
worked out soon. The MoPH has asked MSH to
cost out the current package in its entirety. This
costing exercise should provide guidance to the
MoPH and its partners in finalising the definition
of the package and its schedule of implementation.
Leading Issues
What Does a Basic Health Services
Package Mean?
During the course of discussions with MoPH,
donors, UN agencies and NGOs, it became clear
that the concept of a basic package of services
meant different things to different people. For
some, the interventions in the Basic Health
Services Package should be the only ones to be
implemented in health facilities. For others,
additional interventions, especially medical care
of adult males, was important for the credibility
of the system. Other specialised services, such
as dentistry, eye care and so forth, were also
seen as “essential,” though there was general
agreement that these might not be supportable
through the national MoPH budget or donor
donations to it. For others, the Basic Health
Services Package represented a “minimum
package” of interventions that would be
guaranteed at all appropriate levels of the health
system, but that would form only a core, not the
entirety, of what would be available through the
public health system. Finally, the view most
forcefully articulated by the few MoPH
representatives interviewed was that the Basic
Health Services Package represented what would
be available in the most underserved parts of the
country – those areas where, for the variety of
reasons mentioned throughout this paper, even
these few essential interventions are not currently
available. In other areas, especially urban areas,
the MoPH would continue to try to provide the
fullest possible range of services.
In fact, the strictest interpretation of the public
health approach would be that only those services
that are included in the Basic Health Services
Package should benefit from public funding. A
different set of interventions could be offered at
different levels of the system, of course.
Nevertheless, all publicly funded health services
would be offered in strict conformance with the
policies and strategies detailed by the MoPH and
its implementation partners for addressing the
(for now) seven areas. This concept, while difficult
to swallow, is quite important if the health
indicators of Afghanistan are to improve.
Unfortunately, few Afghan health personnel are
trained in public health. An interview with six
Kabul-based hospital physicians (one general
practitioner, two internal medicine specialists,
one ear, nose and throat (ENT) specialist, one
dermatologist, and one OB/GYN/general surgeon)
was revealing. Their concerns were entirely
patient – rather than population – oriented. They
asked what one does for diabetes, for
hypertension, for breast and/or cervical cancer,
among other relatively common chronic diseases
of adults. As clinical practitioners, they expressed
the view that the lives of individuals affected by
these conditions are as important as those who
suffer from the more common conditions. The
MoPH, the staff of which is also drawn from the
clinical community, is undoubtedly sympathetic
to the sentiments expressed by the group of
physicians described above.
And they should be. Making choices between
public health programmes is a relatively detached,
office-based activity. The ethical dilemma is
Issues Paper Series
Afghanistan Research and Evaluation Unit (AREU)14
much more real to the clinician who is faced with
the difficult task of telling a patient that nothing
can be done, even when effective interventions
are available in other parts of the world. This
same debate is now being conducted in the global
humanitarian literature. Afghan political and
health officials, together with their funding and
implementing partners, will have to decide on a
policy-making level what the Basic Health Services
Package means. Fundamentally, the choice is
between a minimal core of activities that will be
guaranteed throughout a health system that will
continue to provide maximal care to all, no matter
how costly, and a small package of affordable
services that will provide the most care to the
most needy people, but that will deny others
access to the care they need.
“Vertical vs. Horizontal” Programmes
Should the interventions included in the final
version of the Basic Health Services Package be
provided by polyvalent
health workers or by
specialists in the details
of each programme
concerned? That is,
should every facility
have a TB control
officer, a malaria
control specialist, an
epidemiology (EPI)
nurse, one or two people trained in IMCI, a
nutritionist, a physiotherapist, a mental health
practitioner and so forth, or should one health
worker be capable of providing multiple services?
Experience shows that programmes are more
effective when they have dedicated personnel
and a distinct management structure. On the
other hand, having separate supervisors, vehicles,
reporting systems and implementing personnel
for each programme is clearly duplicative and
inefficient.
Obviously, specialists will not be available at the
community level, where most basic health care
in Afghanistan will have to be provided. Here,
there is no choice but to have a polyvalent worker
capable of implementing a small core of
manageable tasks. At the basic health centre as
well, staff will usually be limited, sometimes only
to one male and one female worker. As one goes
up the line, however, it may be possible to
increasingly specialise until, in the regional or
national MoPH, each programme should have an
individual responsible for formulating policy,
testing and communicating strategies, overseeing
a specific part of an integrated information system,
coordinating training programmes and so forth.
This kind of system, from central specialist to
peripheral generalist, might be called “diagonal.”
It is clearly best-suited to the needs of Afghanistan,
but the roles of each category of worker at each
level of the primary health care system will have
to be clearly specified and frequently monitored.
Levels of Care (“push-down” of services)
As implied above, one of the crucial tasks of the
MoPH in regard to the Basic Health Services
Package will be to determine who can do what.
As discussed in the maternal health section above,
physical access to services is a major constraint
to primary health care in Afghanistan. In order
to partially overcome this problem, it seems
important to provide as many basic services as
possible where the
health problems are
most prominent – in the
villages themselves.
However, some of the
interventions specified
in the Basic Health
Services Package are
sophisticated and
beyond the reach of
community health workers. Opinion differs as to
which these are.
Nevertheless, it seems reasonable, in the Afghan
context, to recommend that the MoPH allow CHWs
to treat certain conditions for which care might
not be sought in a sufficiently timely manner at
fixed health facilities. For example, training a
CHW to diagnose diarrhoea and to provide
instruction to a mother in oral rehydration is
obvious. Allowing diagnosis and treatment of
malaria in the community is perhaps more
problematic: purists would insist on microscopic
confirmation of each case in order to minimise
the development of antimalarial drug resistance.
However, one could allow CHWs to provide
chloroquine as a first-line treatment (most malaria
in Afghanistan is due to chloroquine-sensitive P.
vivax infection). If clinical improvement is not
noted within 24 hours, patients can be referred
to the basic health centre. Along the same lines,
though strong objections have been raised in
Physical access to services is a major
constraint to primary health care in
Afghanistan. In order to partially overcome
this problem, it seems important to provide
as many basic services as possible where the
health problems are most prominent – in the
villages themselves.
Afghanistan Research and Evaluation Unit (AREU) 15
The Public Health System in Afghanistan: Current Issues
some countries to allowing village volunteers to
treat childhood pneumonia with antibiotics (usually
cotrimoxazole), this would be desirable in
Afghanistan. Only time can tell if CHWs can learn
to assess and diagnose pneumonia on the basis
of rapid breathing, and to dispense antibiotics in
a way that is understandable to the caretaker.
Finally, among these examples, the question of
whether or not non-physicians should be allowed
to perform surgery, especially Cesarean sections,
is discussed above. The issue of level of care is
quite important in Afghanistan's heavily
medicalised health system in which doctors have
maintained control over many interventions that
could be performed by less highly-trained workers.
The health system will probably have to become
more flexible, more permissive and more creative
in the future. Nevertheless, all new policy
decisions, except those that have been
indisputably successful in other countries, should
be tested in pilot areas and evaluated before
their final adoption.
Special Needs of Vulnerable Populations
In addition to the development of a Basic Health
Services Package, an effective public health
programme makes sure that the needs of the
most vulnerable segments of the population are
adequately addressed. In Afghanistan, these
include returned refugees, internally displaced,
and drought-affected people. Basic needs,
according to minimum standards as outlined in
documents such as the Sphere Project, must be
met.10 Population-based mortality and nutrition
surveys, such as those carried out in Badghis
Province and planned for the rest of Afghanistan,
should be used to establish baseline rates. Where
rates are higher than commonly accepted
threshold values, rapid intervention in these areas
should be prioritised.
The number of returning refugees from Pakistan
has been far higher than predicted – by mid-May
2002 about 500,000 returnees had been registered
by UNHCR. UNHCR is providing up to US $100 per
family (more for those travelling long distances),
but unless adequate food, water and shelter are
provided to all along the path of return, the
health status of this population could deteriorate
rapidly. Even later, unless returnees are re-
integrated into villages in rural Afghanistan there
is a risk that peri-urban shantytowns could develop,
with the inadequate water and sanitation and
relative inaccessibility to health care services
that usually accompany these situations.
Finally, the plight of women in Afghanistan,
featured prominently in many reports, should
also be highlighted here. Reproductive health,
including family planning needs in addition to
safe motherhood is often neglected in the early
stages of health system reconstruction. Other
health problems, caused in part by the low status
of women in Afghanistan (e.g. high mortality from
tuberculosis) need to be identified and addressed.
Finally, poor household health behaviours,
including care-seeking behaviours, need to be
changed through intensive, but effective, health
education campaigns.
Afghanistan shares an important characteristic
with other post-conflict settings. Although it is
struggling to rehabilitate its structural and human
infrastructure through the slow and steady process
of development, it still has a substantial number
of “pockets of vulnerability” where relief, not
development, should be the order of the day.
The objectives of these two spheres of activity,
the intensity of effort required to attain those
objectives, the technical interventions and the
timeframe for reducing excessively high rates of
morbidity and mortality can be quite different.
It is the job of the MoPH, the donors and the
implementing partners to address both relief and
developmental needs simultaneously. This will
be a real challenge for a country where political
stability is still not ensured, where many donors
have expressed interest, but not yet commitment,
and where many NGOs have institutional
philosophies and capabilities that enable them
to work in either relief or development, but not
in both.
Common Denominators
One useful characteristic of the Basic Health
Services Package is that all of the interventions
that will eventually be adopted in the final version
have 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 of
water at the Chaman refugee camp in the Balochistan province of Pakistan and the incidence of bloody diarrhoea.
Issues Paper Series
Afghanistan Research and Evaluation Unit (AREU)16
that can be planned for
at the national level.
The content of these
features will be different
for each programmatic
element, but the skills
required to deliver that
content are similar.
Community Education
Although little data is available, household
behaviours for health are said to be in need of
substantial change in Afghanistan. According to
informants of this report, prevention is rarely
practiced. This is true even of basic requirements
such as breastfeeding, which is of reasonable
duration, but is started late and is not exclusive
for an acceptable time. Recourse to traditional
remedies for almost all of the proposed diseases
of epidemiological importance are common, but
are of questionable impact.
In general, care-seeking behaviour is not well
documented. The proportion of people whose
primary source of health care is in the
traditional/religious system, the private
medical/pharmacy
sector or the public
health system is not
known at this time. Of
course, many people
“shop around” for health
care, moving between the systems or taking
advantage of the strengths of each.11
Research into the attitudes and practices of the
population regarding their own health and that
of their children could provide very useful
information for the planning and implementation
of health education activities.
Both national and international NGOs are providing
a great deal of health education at MCH and basic
health facilities. But the communication of good
behaviour is frequently not enough. Messages
need to be reinforced on a regular basis, from
different sources, and
initial positive
behaviours need to be
reinforced in a variety
of ways in order to bring
about lasting change.
The use of mass media
should be explored.
There is a tradition of health education by radio
in Afghanistan, especially through the REACH
programming of the BBC. The Aide-Memoire
suggested the development of radio programmes
for women as a quick impact project, and UNICEF
is currently planning to use radio for delivering
health messages. Again, the content of the
messages can be varied, but the need for health
education at community level is pervasive.
Training
Building human capacity was probably the most
commonly cited need of the Afghan public health
system. There are a number of reasons why human
capacity of the system is currently deficient.
Medical education under the Soviet regime was
not responsive to the public health needs of the
population. As evidenced by discussions with
Afghan doctors, the
emphasis was on
curative care and
notions of public health
are poorly developed.
As mentioned above,
medical progress has not been well incorporated
into Afghan medical schools. Salaries are very
low. There are real disincentives for doctors to
move to rural areas. Finally, there are too many
doctors in relation to other categories of health
workers that might be better suited, for a variety
of reasons, to provide basic health services to
the population.12 Other important reasons for
limited capacity include the more general collapse
of an already limited educational system,
compounded by the Taliban ban on girls’
education, and the brain drain of many of the
best and educated immigrating to the West.
11 The sectors themselves are not very distinct. In Kabul for sure, and undoubtedly elsewhere, all government doctors maintain
private practices in order to augment their meagre salaries. Other cross-system activities also take place. Anecdotally, one
informant 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 than
the 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 the
most commonly cited need of the Afghan
public health system.
Afghanistan Research and Evaluation Unit (AREU) 17
Research into the attitudes and practices of
the population regarding their own health
and that of their children could provide very
useful information for the planning and
implementation of health education
activities.
The Public Health System in Afghanistan: Current Issues
To redress this situation, plans are being
implemented to vastly increase the number of
mid-level health workers, including nurses,
midwives and auxiliary midwives. Two- and three-
year pre-service training programmes in Kabul
are being heavily supported by USAID and UNICEF
and are being implemented by IMC and other
partners. There are plans underway to extend
pre-service training to the other major regions
of the country. Nevertheless, pre-service training
is a long-term project.
There is a need to
develop sound in-service
training programmes for
all categories of health
worker, including
physicians. Much of this
work is underway and
more is planned, but for the most part it is
occurring in an uncoordinated and project-wise
fashion. The MoPH should devise a coherent
training strategy for implementation by NGOs and
other partners. Again, content should be tailored
to the Basic Health Services Package.
Health Information Systems (HIS)
The other prominently mentioned deficiency of
the Afghan health system on which all contacts
agreed is the quasi-total lack of usable
information. As with so many other features of
the system, some information is available on a
project-by-project basis, but little systematically
collected data is used to formulate national
policies and strategies or to guide programmatic
activities.
There are numerous surveillance activities
underway, though. The WHO/UNICEF-led polio
eradication effort is a good example in this regard.
The polio surveillance effort should be expanded,
and the system should be made to accommodate
reporting on other important conditions. This is
being planned. The measles mortality reduction
strategy has also made a concerted effort to
improve reporting. Nevertheless, reports of
diseases, even when reporting is limited to a
small number of major conditions and diseases
of epidemic potential, are only helpful to a limited
extent. Process indicators, designed to inform
on the progress of programmatic strategies, also
need to be incorporated into effective health
information systems (HIS).
Most of the organised, coordinated, national-level
information activity is taking place through AIMS
(Afghanistan Information Management Service),
an apparently successful innovation of UNDP and
UNOCHA. Still, information that will be most
useful in reducing the poor health indicators of
Afghanistan will be information that can be
collected, analysed,
interpreted and used at
the most local level
possible. It is gratifying
to see the extent to
which basic health
centres and MCH clinics
(at least the ones we
visited) are aware of their geographical catchment
areas, their target populations and some of their
coverage results. This kind of local information
for local use needs to be expanded throughout
all projects currently operating, and eventually
to national programmes that intend to implement
the Basic Health Services Package.
Operational Research
Throughout this document the need for
information has been stressed. Targeted research
is important to the development of appropriate
policy in post-conflict health systems.
In Afghanistan, little is known about the following
areas at the present time:
Household health practices, including
breastfeeding, weaning, treatment of
childhood illnesses;
Care-seeking behaviours;
Household expenditures on health by type of
provider;
Levels of mortality and malnutrition;
Prevalence of major micronutrient
deficiencies, specifically iron, iodine and
vitamin A;
Rates of seroconversion (development of
immunity) to measles vaccine at six months
of age;
Capacity to conduct appropriately selected
and designed research should be developed
and donors should prioritise supporting
operational research and not just project
implementation.
Issues Paper Series
Afghanistan Research and Evaluation Unit (AREU)18
Rate of impregnated bed net use in most
areas of the country;
Means of redistributing resources
geographically;
Resistance to antibiotics and antimalarials;
Incidence, diagnosis, treatment and
proportional mortality of childhood
pneumonia;
Seroprevalence of HIV in the
general population high-risk
subsets; and
Cause of disability, including
land mine injuries, birth
injuries and motor vehicle
accidents, among others.
This list could be much longer,
as additional problems are
recognised. Capacity to conduct
appropriately selected and
designed research should be
developed and donors should
prioritise supporting operational
research and not just project
implementation.
Programme Management
The final element that all public health
programmes have in common is the need for
strong management. Policy formulation and the
development of effective strategies are an
important part of management, but they need to
be complemented by strong oversight, periodic
monitoring and well-designed, constructive
evaluation. The MoPH is admittedly weak in this
area and will require substantial external
assistance over the next few years. Some of this
assistance is already in place, at least for the
short term, but additional commitments by donors
will be required. Given the ideas currently being
proposed as to how
services would be
delivered in Afghanistan,
the managerial role of
the MoPH is paramount.
One first step in
effective management
is the definition of clear,
realistic objectives. The National Development
Framework (NDF), seeking early results, mentions
that child mortality in Afghanistan should be cut
by half in two years, clearly an impossible dream.
In post-conflict settings, the quest for rapid results
in order to maintain the interest of the donors
has competed with the recognition that the
rebuilding of political, economic and social systems
is a slow process and that rushing things only
increases the likelihood of an unsatisfactory
outcome. While the health sector does not work
in isolation and needs to be sensitive to political
concerns, decisions must be made as to what the
MoPH is trying to achieve. Setting quantifiable
objectives will, to a certain extent, dictate the
interventions and strategies to be implemented.
For example, setting a national objective of
mortality reduction of children and pregnant
women requires different interventions than one
of ensuring minimum services in all areas of the
country, including those that are currently
underserved. Working in concert with the
international community
to eliminate polio from
Afghanistan requires a
different level of
resources and very
different strategies than
training an adequate
number of mid-level
health workers to
In post-conflict settings, the quest for rapid
results in order to maintain the interest of
the donors has competed with the recognition
that the rebuilding of political, economic
and social systems is a slow process and that
rushing things only increases the likelihood
of an unsatisfactory outcome.
Afghanistan Research and Evaluation Unit (AREU) 19
Ronald Waldman
The Public Health System in Afghanistan: Current Issues
provide basic services. Certainly a mix of process
and outcome-oriented objectives can, and should,
be developed. But no matter how many different
agendas they seek to accommodate, these
objectives should be realistic, well defined and
clearly articulated. Only then can a set of
appropriate interventions and strategies be
developed.
A word is in order regarding coordination, another
important aspect of effective management,
sometimes referred to as the “slowest common
denominator.” Coordination in Afghanistan has
been difficult to date.13 This has been true not
only between the actors, but within the groups
themselves. There is potential for disagreement
between different bodies of government, for
example, such as between the AACA and the line
ministries, and between the several line ministries
that have responsibility for the provision of health
services, including the
MoPH and the Ministry
of Higher Education.
There are other
ministries that are
involved in health as
well. Donor
coordination is always a
potential – and usually
a real – problem. Donors
consulted during the
course of writing this report seemed generally
satisfied with the level of informal donor
coordination, though most felt that the formal
mechanisms which have been formed are less
productive.
The UN agencies are, to a certain extent, vying
for prominence. With different institutional
histories in Afghanistan, and generally unproven
records, they are struggling to establish
relationships of trust with the government, donors
and NGOs. If the performance-based contract
scheme (see Section III) is put into place, even
in modified form, the role of the UN agencies will
be further called into question. On the other
hand, given the lack of managerial and technical
expertise in the MoPH, it seems reasonable to
suggest that the UN agencies provide substantial
assistance in at least an advisory, if not a more
active, capacity. UNICEF seems particularly
capable of filling this role, and it has organised
a series of admirable research and programmatic
activities. These roles, including national level
information gathering through surveys and the
development of routine information systems; the
design and implementation of national level
technical intervention programmes, such as those
planned in micronutrient supplementation; safe
motherhood and measles vaccination initiatives;
and the assignment of technical advisers to the
MoPH should continue. The desired role of the
UN agencies in the health sector should be made
more explicit in the next JDM and funding for
these agencies should be allocated.
Finally, NGO coordination is in a typical state of
affairs. There are a number of NGO coordinating
bodies for both
international and
national NGOs, and the
need to coordinate the
coordinators is an issue
that was mentioned by
several of them.
Established NGOs and
new arrivals, relief-
oriented and
development-oriented
NGOs, primary health care and specialised
agencies, government-funded and privately
financed, all should be represented by the
coordinating bodies. This is difficult, if not impos-
sible. In fact, one of the principal coordinating
structures, the Agency Coordinating Body for
Afghan Relief (ACBAR), has found itself performing
a function of information exchange far more than
one of providing leadership and representation
of the NGO “community.” While information
exchange is a clear necessity in the dynamic and
constantly changing situation of Afghanistan,
NGOs do need to be included in the decision-
making processes of government and the UN to
the 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 coordination
and some other relevant issues in the context of Afghanistan from an NGO perspective. 9 April 2002.
Issues Paper Series
Afghanistan Research and Evaluation Unit (AREU)20
While information exchange is a clear
necessity in the dynamic and constantly
changing situation of Afghanistan, NGOs do
need to be included in the decision-making
processes of government and the UN to the
degree that their presence in the field
warrants.
Whatever the final content of the Basic Health
Services Package, delivering health services to
the population will pose an enormous challenge
to the MoPH. Many of its facilities – from hospitals
to basic health centres – were destroyed over the
years. The rehabilitation and re-equipping of
these 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 offered
will be difficult.
WHO, using its Health Mapper programme, has
made one attempt to do so. An Infrastructure
and Health Atlas of Afghanistan was produced in
February 2002. It details the location of the
known functioning and non-functioning basic
health centres, showing that the former are
concentrated for the most part in and around
Kabul and in the eastern region. Although these
are the areas of highest population density in
Afghanistan, it is worth noting that the ratio of
basic health centres to population ranges from
approximately one per 40,000 in the central and
eastern regions to approximately one per 200,000
in the south. Nineteen districts had no health
facilities at all. A more comprehensive, active
survey of all health facilities and associated
resources is currently being planned by MSH. It
is scheduled to begin in July and to be completed
in September 2002.
Even without a detailed inventory of facilities
and health care personnel, it is clear to all that
while the more densely populated parts of the
country may be adequately served, in quantity if
not in quality, there is a woeful shortage of
functional health service delivery points and
health personnel in most of the country. For
personnel, the unequal distribution of resources
is true for all levels of care, from traditional birth
attendants (of which there are only 30% of the
estimated number required) to physicians (of
III. Managing the Health System
which more than 50% of the approximately 4,000
are said to be in Kabul alone). Of Afghanistan’s
33 provinces, only 11 currently have the capacity
to deliver emergency obstetrical care.
The majority of health care in Afghanistan is
provided at present through NGOs. It is estimated
that more than 80% of functional health facilities
have some form of NGO involvement. The number
of NGOs working in the health sector is large, the
scope of their work varies considerably and, for
the most part, they are undertaking to deliver
services in discrete project areas. NGOs are
providing support in the form of physical
rehabilitation of premises, equipment, salary
support for personnel, training and direct service
delivery. While some are working through MoPH
and/or Ministry of Higher Education auspices,
many have bypassed government structures and
are operating independently (albeit with
government permission). While most NGOs are
working to provide general primary health care
services, some are quite specialised, for example,
IAM for eye care, ICRC for surgical and orthopaedic
services, HNI for malaria and leishmaniasis control,
MedAir and MSF for TB control, and others.
Although a number of NGOs are attempting to
address the needs of particularly underserved
areas in the central and southern parts of the
country, the overall distribution of NGO activities
is uneven, with a concentration in the urban areas
and areas near the Pakistani border. Many NGO
activities began as cross-border operations,
headquartered in Pakistan, and their reach
extended only to the eastern and, to a lesser
extent, the north-eastern areas of Afghanistan.
The conflict over much of the past 15 to 20 years
dictated which areas could be accessed by even
the most daring organisations. Logistical
constraints also played an important role in
determining the deployment of personnel and
services.
If an efficient and effective national health system is to be developed in the coming years, the
following 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; and
4. The relatively uncoordinated and undirected efforts of the NGOs that are providing the bulk
of health care services.
Afghanistan Research and Evaluation Unit (AREU) 21
The Public Health System in Afghanistan: Current Issues
A draft of the Aide-Memoire of the JDM to
Afghanistan on the Health, Nutrition, and
Population Sector (9 April 2002) presented a
proposal for resolving these problems. The JDM
suggested that basic services could be rapidly
extended to underserved areas (and throughout
the country) by the adoption of a management
system structured around PPAs between the MoPH
and the NGOs and/or other private sector
elements.
Under the PPA scheme, the MoPH would be
responsible for establishing health care priorities
for the Afghan population and defining a basic
package of services (discussed above) that would
form the core of health facility activities
throughout the country. Quantifiable, time-linked
targets for improvements in health service delivery
and, presumably, population health status would
also be established. The MoPH would prepare
“requests for proposals” from the NGO community
and invite competitive bids for contracts to provide
essential health services to underserved areas.
It is suggested that one contract be awarded per
province, with the NGO contractee responsible
for the provision of all health services – from
hospital management to community-level care.
Awards would be made in a transparent manner.14
The NGO awardee would be paid on a per-capita
basis for the provision of health services, but only
if its performance was acceptable in relation to
the predetermined indicators, as evaluated by
both the MoPH and independent audits.
The PPA scheme is seen to have the following
real and potential advantages, as outlined in the
Aide-Memoire, which states that PPAs would:
•allow the government to take advantage of
the presence of international and local NGOs
in the health sector, to more clearly define
a common set of services and to promote
adherence to a national health policy;
•establish a more formal, hopefully
constructive, relationship between the
government and the NGOs;
•ensure a more equitable distribution of health
services;
•contribute to the decentralisation of decision-
making, by situating day-to-day operations
at the provincial level; and, perhaps most
importantly,
•allow the MoPH to restrict its functions to
the management of the NGO contracts and
to forgo, to a large extent, the direct delivery
of health services through a large and
cumbersome civil service corps, if scaled-up
to 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 of
developing and managing large contracts is
enormous. The MoPH does not possess the skills
to do so and substantial technical assistance would
undoubtedly be required over a long period of
time. The potential for the award process to be
influenced by personal relationships, bribes and
other forms of corruption is always present. The
system will probably be expensive for the
government, since the NGOs constitute a
middleman that would not be present if the MoPH
were to provide services directly. (On the other
hand, preliminary results from the Cambodia
experience show that household expenditures on
health were lowered as people made greater use
of the higher-quality, lower-cost public facilities
and sought health care in the higher-cost private
sector less frequently). Finally, and especially
significantly in the Afghan context, monitoring
and assessment of NGO performance, the principal
element of the contract, requires the regular
collection and analysis of accurate data, something
which is essentially non-existent at present.
The PPA approach in Cambodia is described in
more detail and the results of an early,
independent evaluation are presented elsewhere.15
In brief, utilisation of facilities, especially by the
poor, antenatal care visits, tetanus toxoid
immunisation 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 ADB
in Cambodia, each bid consisted of two proposals, one technical and one financial. A panel consisting of representatives from
the MoPH, UN, and the NGO community judged the technical merit of each bid. When more than one bid was determined to
be 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 in
Cambodia. ERD Policy Brief #6, Asian Development Bank, March 2002.
Issues Paper Series
Afghanistan Research and Evaluation Unit (AREU)22
facilities. Quality of care in both health facilities
and hospitals also improved, though it is not clear
what criteria were used to determine this. Finally,
as mentioned above, though government costs
were higher, household expenditures were lower
in the contracted districts than in control districts.
These results are encouraging, though they are
characterised by the authors as “preliminary and
indicative,” and no data regarding curative care
are presented. However, it is not clear to what
extent the Cambodia experience can be replicated
in Afghanistan. Some of the implications of its
adoption for the various actors in the health
sector are outlined below.
It is extremely difficult to get hard data regarding
the cost of providing health services in Afghanistan.
What is certain,
however, is that
external funding,
currently estimated at
80%, will be required for
many years to come.16
The Aide-Memoire
estimated the
requirement for
delivering hospital and
basic health services to
be between US $230 and
US $310 million over the next five years, and the
rehabilitation and equipping of existing
infrastructure an additional US $100 million. The
World Bank will undoubtedly be one of the largest
donors to the PPA scheme and a funding proposal
is currently being prepared. The European
Commission (EC) is considering a contribution of
similar magnitude, perhaps about US $10 - $15
million per year for the next five years (following
on a contribution of approximately 20 million
euros this year). Other donors have not yet
determined their funding levels for health, but
it is expected that additional funding will become
available from a considerable number of bilateral
donors. It will be needed.
Whatever final amount becomes available, a high
degree of donor coordination will also be
desperately needed. Although it has been
proposed in other countries that donors contribute
to a common fund in order to allow ministries of
health to implement their national plans, this
mechanism has proven difficult to put into practice
for a variety of reasons, mainly involving donor
requirements for accountability. Bilateral, direct
funding from donors to NGOs can certainly be
done under the PPA scheme, as long as donors
respect both the technical content of the MoPH
national plan for expanding services, i.e., the
Basic Package of Health Services, and the
contractual agreements agreed upon by the MoPH
and the NGOs. Extensive donor funding of a large
variety of activities and services outside of the
Basic Health Services Package and/or funding of
NGOs based on criteria other than the performance
criteria developed by the MoPH can only serve to
undermine the credibility of the MoPH and its
ability to manage the
health sector, and
interfere with its ability
to achieve its objectives.
If the principal actors in
the health sector are to
be the government as
managers and the NGOs
as implementers, the
role of the three UN
agencies (WHO, UNICEF,
UNFPA) that are
currently involved in the health sector is called
into question. Of course, they will continue to
be called upon to provide technical assistance to
the MoPH, both in the design of the contract
terms and in the bidding process as well as in
their areas of technical expertise, but their role
as “lead agency,” or ”secretariat,” for the health
sector is less clear. Whether or not an
implementing function would be reserved for
them in the national vaccination programmes,
other areas of communicable disease control,
nutrition and safe motherhood, would need to
be worked out. It should be mentioned that at
the time of this report no UN agency had yet been
designated as the overall secretariat of the health
sector.17
When this report was being prepared, the NGOs
were, 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 for
reproductive health in general.
Extensive donor funding of a large variety
of activities and services outside of the Basic
Health Services Package and/or funding of
NGOs based on criteria other than the
performance criteria developed by the MoPH
can only serve to undermine the credibility
of the MoPH and its ability to manage the
health sector, and interfere with its ability
to achieve its objectives.
Afghanistan Research and Evaluation Unit (AREU) 23
The Public Health System in Afghanistan: Current Issues
JDM proposal. At the
request of a number of
them, a meeting was
held to present, albeit
briefly and
incompletely, the main
points of the PPA as
described in the Aide-Memoire and the Cambodia
evaluation report (see above). From this meeting,
and from interviews with individual representatives
of a considerable number of NGOs (see Appendix
A for a list of interviewees), it was clear that the
NGOs recognised the problems that the PPA
scheme is meant to address. There was consensus
that the proposal had considerable merit on paper,
but there were questions regarding the feasibility
of its implementation in the Afghanistan context.
This was true even with the understanding that
in a competitive bidding process there would be
“winners” and ”losers,” and that the system
seemed to favour those larger NGOs that had
longer experience in Afghanistan. Some NGOs
responded favourably to the idea that it might
be to their advantage to form formal or informal
partnerships with others working in complementary
areas in order to be more competitive. It should
be pointed out, though, that the sample of NGOs,
(both international and national), interviewed as
part of this analysis is hardly
representative of the large NGO
community currently working in
the health sector in the country.
Perhaps the most important
observation from the NGOs is
that, like the government, they
also do not possess the capacity
to provide even basic services
across the levels of the health
system on a provincial basis.
Even the largest of the health
providers in the country, the
Swedish Committee for
Afghanistan (SCA), supports only
basic health centres. Though
their representative expressed
a positive attitude toward the
government contracting
approach, recognising that it was
a way to increase
government control and
to unify a fractured
health system, he felt
that SCA would have to
limit its current
geographical scope in
order to provide services at more than one level
of the system. Similarly, other NGOs expressed
reluctance to take responsibility for the delivery
of services over a large area. Different NGOs
suggested that contracts be limited to the provision
of services at specific facilities, on a district-by-
district basis, or for a cluster of districts where
the number of facilities within a district was
particularly small.
It was suggested that NGO representatives sit
with the MoPH when the technical terms of the
contracts and the performance indicators are
being designed. NGOs, by virtue of working at
the community level, may have a better idea of
the kinds of services that are most required and
most desired by the communities, of the most
effective service delivery strategies, and of
reasonable expectations for performance. Leaving
the MoPH and its advisers in complete charge of
the 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 and
UNICEF was given responsibility for nutrition, childhood vaccinations and safe motherhood. UNFPA will be responsible for
reproductive health in general.
Perhaps the most important observation from
the NGOs is that, like the government, they
also do not possess the capacity to provide
even basic services across the levels of the
health system on a provincial basis.
Issues Paper Series
Afghanistan Research and Evaluation Unit (AREU)24
Sarah Telford for UNICEF
a “top-down” approach that should be avoided.
Similarly, it was pointed out that the perceived
advantage of decentralisation accorded to the
PPA scheme might, in fact, be a detriment. NGOs
reported that local health officials, at province
and district levels, already see themselves as
being “in charge.” Unless they were part of the
contracting process and fully informed of the
agreements made between the NGOs and the
MoPH, central and provincial MoPH authorities
might have different sets of demands and
requirements. Improved and effective
communications between the different levels of
the MoPH would have to be established. Finally,
the acceptability of a formal contractual
agreement with government in light of the
advocacy and witnessing role of NGOs and their
function as independent observers of the scene
in a country as politically complicated and as
fragile as Afghanistan was mentioned.
The experience of one NGO with which the PPA
proposal was discussed in some detail, HNI, is
worthy of mention for a variety of reasons. For
one, HNI is currently implementing two PPA
agreements in Cambodia and has considerable
experience with the system. HNI is also currently
supporting two distinct kinds of programmes in
Afghanistan. One is a primary health care
programme in Shinwar district in Nangarhar
Province in the eastern region. HNI is providing
support to the University Hospital at the regional
(provincial) level, to a rural 40-bed hospital in
Ghani Khel that serves a cluster of districts with
a population of approximately 300,000, and to
two basic health centres that form the base of
the PHC pyramid, or “cluster.” The other major
HNI activity in
Afghanistan is technical
support to malaria
control. A specialised
team has been
promoting, monitoring
and evaluating the use
of impregnated bed nets
and other materials,
cattle sponging and
larva-eating fish. They
have been researching
and monitoring antimalarial drug resistance
patterns and contributing to the development of
national malaria control policies.
The primary health care “cluster” seems tailor-
made for the PPA process, assuming that the
performance indicators are designed according
to reasonable expectations that might be informed
by the HNI experience (and others) to date.
Interestingly, HNI reports that the initial contracts
in Cambodia significantly underestimated the
rapid increase in utilisation of government facilities
that took place after the NGO contracts were
awarded. As a result, because the contractual
payments were made on a per-capita basis for
services offered, and because they had to serve
a substantially greater number of people than
that for which they had contracted, HNI lost a
considerable amount of money. They urge that
safeguards be built into the contracts in
Afghanistan until appropriate baselines can be
established. Nevertheless, and in spite of the
fact they their contract gave them only
management oversight, not control, of health
service delivery in their districts, HNI feels that
their experience was quite positive.18 They
recognise the advantages in the short- to medium-
term of a small, but capable, MoPH that would
be involved in policy making, monitoring and
supervision, but to a much lesser extent in service
delivery. Similarly, they feel that a public/private
partnership system would allow for systems to be
“jump-started” in order to provide services into
rural areas quickly. Finally, the closer involvement
of NGOs with the MoPH at a national level would
allow for capacity-building and an eventual, but
unforeseeable at this time, transfer of
responsibilities back to
the government.
On the other hand, the
role of the technical,
“vertical,” malaria
programme is less clear.
HNI tries to provide
technical support to all
government and NGO
malaria control efforts
at present. Technically
18 In Cambodia, two kinds of contracts were offered: In one, “contracting-in,” – the kind HNI had – NGOs gave technical and
managerial support to civil service staff and inputs were provided through normal government channels. HNI reportedly had
difficulties with drug deliveries, timely payment of salaries, etc. In the other, “contracting-out” model, NGOs had complete
control over resource provision and health service delivery, and they hired their own staff.
Although a sense of urgency is conveyed by
the aide-memoire and calls are made for
“quick” and “rapid” action, a longer-term
vision might serve the country best. The
limited existing capacity on the part of both
government and NGOs, the multiplicity of
actors and the cautious eye through which
most donors are viewing the current situation,
suggests that a slow, phased-in approach
might be more warranted.
Afghanistan Research and Evaluation Unit (AREU) 25
The Public Health System in Afghanistan: Current Issues
specialised programmes, such as HNIs and others
mentioned above, are not currently provided for
in the PPAs. They need to be.
In summary, the PPA proposal of the JDM seems
acceptable to the principal actors in Afghanistan’s
health sector and seems, in principle, to address
some of the major existing problems. At this
stage, its designers need to be further informed
of the characteristics of Afghanistan’s political
structure (when that becomes clearer and more
stable) and the capacity of its line ministries.
Although a sense of urgency is conveyed by the
Aide-Memoire and calls are made for “quick” and
“rapid” action, a longer-term vision might serve
the country best. The limited existing capacity
on the part of both government and NGOs, the
multiplicity of actors and the cautious eye through
which most donors are viewing the current
situation, suggests that a slow, phased-in approach
might be more warranted. They also need to
understand better the capabilities and limitations
of the proposed principal partners to the MoPH:
the international and national NGOs that are
currently providing the majority of the health
services. The NGOs need more information
regarding the current proposal and the past
performance of PPAs, its benefits and
disadvantages, and its short- and longer-term
implications for their work in Afghanistan and
elsewhere. Although there is little doubt that
when large contracts are offered, many
organisations will be tempted to bid, it would be
in the best interests of the MoPH to ensure that
the larger and the most proven of the NGOs are
willing to participate. In order to ensure their
full participation, the next JDM should try to elicit
their full participation, at least at a public
discussion of the proposal. It would also be
constructive for the JDM to provide a number of
alternatives to the scheme that is currently under
discussion.
Issues Paper Series
Afghanistan Research and Evaluation Unit (AREU)26
Many of the above recommendations are derived
from interviews conducted for this report, and
several are already in the process of being
implemented.
General Recommendations
1. 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 in order to allow all actors in
the health system to work toward achieving
the same goals and objectives. At present,
most health care delivery in Afghanistan is
done on a project-by-project basis. NGOs or
other entities, including UN agencies involved
in health design, seek funding for and
implement ideas that they feel meet the
needs of the population in accordance with
broad guidelines laid down by donors.
Although the MoPH has issued an excellent
statement of general principles that clearly
articulates the primary health care approach,
there are no specific policies regarding primary
health care programmes that can guide the
activities of health service delivery
organisations or coordinate their actions.
The elaboration of a Basic Health Services
Package is a step in this direction.
2. The authorities in Afghanistan should
consider convening a “loya jirga” for health
in the months following the next JDM. This
might take the form of a meeting of
representatives of each of the major groups
of actors - MoPH, UN, NGO, and private
practitioners - for a true exchange of
information and the joint development of
policy and implementation guidelines.
Communications between the actors has been
a problem. There have been attempts to
coordinate the activities of the NGOs, UN
organisations and the government through
formal and informal mechanisms of
information exchange. However, these have
not been effective, and there has been
insufficient communication between these
categories of contributors to the health
IV. Recommendations
system. In other post-conflict settings it has
been useful to have periodic, general meetings
to review and discuss health policies to
develop consensus around future activities
and to hear about obstacles from the field.
These meetings serve to keep everyone
informed, to create a spirit of cooperation
and consensus and to promote a participatory
style of work. Ensuring the investment of all
groups in the future of public health in
Afghanistan would be a first step in ensuring
its success.
Recommendations on Content
3. The Ministry of Public Health should not set
itself up for failure by promising to deliver
more than it can. Although the draft Basic
Health Services Package is an important step
towards prioritising the essential work of the
health system, there are enormous competing
demands for more than the system can handle.
No one ever feels comfortable designating
important areas of work as “non-essential.”
Yet the hard reality is that according to most
of those interviewed during this consultation,
the Basic Health Services Package, as it is
currently composed, cannot be implemented,
at least not all at once. The MoPH should
develop a schedule for phasing in the
components of the package and a review of
priorities, particularly mental health and
disability services, taking into account the
financial, technical and operational realities
of the current situation. However, donors
should understand that in order to be credible,
the MoPH will have to try to satisfy the needs
of its entire population. NGOs should try to
ensure that the appropriate technical
expertise is available to deal with those
problems that are designated as highest
priority.
4. Following the completion of appropriate
studies, clear policy guidelines should be
developed and enforced for the treatments
of choice for pneumonia, malaria and
malnutrition. The management of common
childhood communicable diseases and
Afghanistan Research and Evaluation Unit (AREU) 27
The Public Health System in Afghanistan: Current Issues
malnutrition should be the subject of an
intensive training programme for
intermediate-level and community-based
health workers. While implementation of the
WHO/UNICEF IMCI initiative would be ideal,
the process is time-consuming and quite
training-intensive. On an interim basis,
shorter, more focused training efforts can be
launched to take advantage of the seasonal
occurrence of some of the target diseases.
5. Primary care services should be “pushed
down” to the community level. This includes
the management of diarrhoea, the initial
treatment of malaria and pneumonia and the
assessment and referral of obstetrical
emergencies. The level at which primary
health care services are offered is a crucial
issue in Afghanistan because of the difficulty
in accessing facility-based services. Such an
approach will require that non-physicians use
drugs and perform procedures that have
previously been restricted to medical
personnel. Because women are often more
adept at community health work, including
vaccination, an appropriate proportion of
women should be trained to do these jobs.
The issue of payment to community health
workers for performing these services also
needs discussion and resolution.
6. The needs of highly vulnerable populations
should not be ignored. Although the current
emphasis is on rehabilitation and
development, there are a considerable number
of returning refugees, internally displaced
and conflict- and-drought-affected populations
whose needs may be different from those of
most Afghans.
Recommendations on Management
7. NGOs should be more involved in the next
JDM and full participation of the donor
community should be assured. NGOs are
relatively uninformed regarding the details
and the implications of the PPAs, the principal
feature of the JDM's recommendations.
Bilateral agreements between donors and
implementing NGOs should be allowed and
encouraged, but the donors should respect
the programmatic priorities of the MoPH and
not pursue their own policies and programmes
independently. Competition between
government and international donors can be
avoided if donors are committed to the same
principles as the MoPH.
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, and where there is substantial
experience in rehabilitating post-conflict
health systems.
9. Consider alternatives to province-wide
health services. At present few, if any, NGOs
are capable of implementing health services
at a provincial level in Afghanistan, as
suggested by the PPA scheme and proposed
in the draft Joint Donor Mission Aide-Memoire.
Alternatives may include contracting services
on a facility-by-facility basis (or for a cluster
of facilities), contracting at a district level
or lower, or contracting several NGOs to
provide services at different levels of the
system within a single province.
10. The place of specialised, vertical
programmes should be carefully considered.
NGOs that are not providing general primary
health care services, (e.g. tuberculosis control,
leishmaniasis control, and perhaps support
and rehabilitation of the disabled), are
providing valuable services. The MoPH should
oversee and manage these activities. NGOs
working in these areas should be accountable
to the MoPH and to the public they serve.
11. A functional health information system
should be created, emphasising accurate,
timely and actionable information. It should
build on the surveillance systems that have
been put in place by the polio eradication
initiative, though indicators of maternal
health, nutrition and food security and
programmatic (process) indicators for all
priority health activities will require different
information parameters.
12. A research agenda to inform policy-making
and service implementation should be
developed and implemented. Operational
Issues Paper Series
Afghanistan Research and Evaluation Unit (AREU)28
research is frequently neglected, and because
relatively little is known about household
health practices, care-seeking behaviours,
and household expenditures on health in
Afghanistan, particular emphasis should be
put on these subjects. Other potential priority
research areas are found in the body of this
report.
The public health system in Afghanistan has a
long 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 for
continued progress. These recommendations are
offered in the spirit of fostering as comprehensive
and as participatory a process as possible. With
the sustained commitment, dedication, and
intensive effort of those involved in public health,
the health status of the Afghan population can
improve substantially over the next few years.
Afghanistan Research and Evaluation Unit (AREU) 29
The Public Health System in Afghanistan: Current Issues
List of Contacts
Afghan Assistance Coordination Authority (AACA)
Leader, Nicholas, Representative
Ministry of Public Health (MoPH)
Fahim , Dr. Abdullah, Director of International
Relations
Ibrahim, Dr. Fazel M., Regional Director for the
Eastern Region, Jalalabad
United Nations
Borrel, Annaliese, Technical Adviser to the Ministry
of Health, UNICEF
Crowley, Joe, Field Officer, Afghanistan
Information 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, Maternal
and 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 Development
Officer, USAID
Lynch, Ellen, Health Officer, USAID (IOM)
Paro, Amy, USAID/OFDA
Sondorp, Egbert, EC
Tully, Anne, World Bank
NGOs
Anastacio, Anita, Country Director, Mercy Corps
International (MCI)
Andersson, Hans Ronny, Health Delegate, ICRC
(Jalalabad)
Brigham, David, Programme Coordinator, IMC
Combes, Jerome, Head of Mission, Action Contre
la 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
Issues Paper Series
Afghanistan Research and Evaluation Unit (AREU)30
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, Agency
for Rehabilitation and Energy Conservation in
Afghanistan (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 Sina
Emergency Hospital
Sadat, Dr. Said Abdullah, General Practitioner,
Ibn Sina Emergency Hospital
Safi, Dr. Hafizudin, Chief of ENT, Ibn Sina
Emergency Hospital
Meeting with NGOs Concerning PPAs
Anastacio, Anita, Representative, MCI
Brigham, David, Programme Coordinator, IMC
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 Generation
Coordinator, CARE
Bang, Carol, Programme Officer, IMC
Benjamin, Judy, Gender Adviser, USAID
Brigham, David, Programme Coordinator, IMC
Brown, Dr. Linda, Medical Coordinator, Relief
International
Cautain, Jean-Francois, Programme Coordinator,
EC
Afghanistan Research and Evaluation Unit (AREU) 31
The Public Health System in Afghanistan: Current Issues
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, Catholic
Relief Services (CRS)
Huff-Rousselle, Peter, Country Representative,
UNFPA
Jaberkhil, Dr. Zahir, Programme Support and
Liaison Manager, Save the Children/UK (SC/UK)
Jain, Valli, M & C Coordinator, Hope Worldwide
Karisson, Marie, Programme Manager, MedAir
Mahaveer, Regional Administrator, Hope
Worldwide
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)
Issues Paper Series
Afghanistan Research and Evaluation Unit (AREU)32
Bibliography
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– Second Draft, May 2002
Auxila P., Guiollaume F.D., Schutt P., Pierre L.G.,
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Benjamin J. Post-Taliban Afghanistan: changed
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the Safe Motherhood Initiative in Afghanistan.
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Duffield M., Gossman P., Leader N. Review of the
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Immediate and Transitional Assistance Programme
for the Afghan People – 2002.
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Ministry of Public Health. Report of the National
Health Sector Planning Workshop,
16-19 March, 2002.
MSF. MSF activities in Afghanistan. 6 May 2002.
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Schenkenberg van Mierop E. NGO Coordination
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Afghanistan Research and Evaluation Unit (AREU) 33
The Public Health System in Afghanistan: Current Issues
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
Issues Paper Series
Afghanistan Research and Evaluation Unit (AREU)34
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 to
Afghanistan
USAID United States Agency for International Development
WB World Bank
WHO World Health Organisation
Afghanistan Research and Evaluation Unit (AREU) 35
The Public Health System in Afghanistan: Current Issues
A Review of the Strategic Framework for Afghanistan, by Mark Duffield, Patricia Gossman and
Nichloas 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 are
available by contacting the AREU office in Islamabad: phone: +92 / (0) 51 227-7260.
fax: +92 / (0) 51 282-5099 email: areu@areu.org.pk.
Recent Publications by the AREU
Issues Paper Series
Afghanistan Research and Evaluation Unit (AREU)36
