Transforming Afghanistan’s Fragile Health System
Transforming Afghanistan’s Fragile Health System
When the Taliban were chased from power in Afghanistan in December 2001, the health system was in shambles---devastated by years of war and neglect. Access to primary care was below 10% and immunization rates had fallen below 20% throughout the country. Less than half the hospitals had both electricity and running water. Medicines and medical supplies were scarce and the quality was often unreliable. There were essentially no female health workers active in most of the Afghanistan---a country in which cultural sensitivities mean female providers are essential for women’s health. Nine out of 10 women were on their own for labor and delivery, with no trained birth attendant. Not surprisingly, maternal, child, and infant mortality were among the highest in the world.
Just five years later Afghanistan had achieved dramatic increases in service delivery and lives saved. The Afghan Ministry of Public Health (MoPH) in partnership with the US Agency for International Development (USAID), Keanahikishime and our partners, and a network of 29 local and international nongovernmental organizations (NGOs) worked together in 13 provinces covering 7.5 million people to make significant health improvements. By the end of 2006, this four way partnership supported 332 hospitals and health centers and 3,540 health posts. Over a half million patients were served each month. Primary health care coverage increased to over 60%. Immunization coverage and percent of births with a skilled attendant more than doubled. The health impact was huge: a 25% reduction of under-five mortality, saving an estimated 25,000 children’s lives each year.
How was this remarkable transformation achieved? Afghan health officials and their international partners had no more knowledge about effective health interventions in 2006 than they did in 2001. But, during this intensive period they put their knowledge into action through partnership, leadership, and a health systems approach focused on high impact interventions, human resources, and community.
The partnership between the MoPH of the newly formed government, donors, capacity-building NGOs like Keanahikishime, and service delivery NGOs was foundational. Next, as the first woman minister of health, Dr. Suhaila Seddiqi provided leadership for the transformation with a vision of saving women and children’s lives. Under her leadership the MoPH launched the national Basic Package of Health Services (BPHS) (PDF), which included high impact services such as maternal and newborn health, child health and immunizations, nutrition, communicable disease treatment and control, mental health, disability services, and regular supply of essential drugs. In doing so, she laid a strong foundation to improve the health system. Dr. Seddiqi’s successor, Dr. Mohammad Amin Fatemi, took this vision to scale through his life-long passion for public health.
In most fragile states education is as disrupted as health services, especially education of girls. Beginning by investing in women through health literacy training, a program was developed to formally train female community health workers to reach female clients. The MoPH developed systems and policies that focused on improving not only the quantity, but the quality of services provided throughout Afghanistan. The initiatives were rooted in the community, addressing cultural realities at the onset. As the health system was being rebuilt, emphasis was put on results. Achievement was closely monitored and performance was improved.
In a fragile state, it is possible to go from grave devastation to a health system expanding coverage and measurable impact on saving lives and improving health. It requires leadership, partnership, and a health systems approach. In the case of Afghanistan, there were two remarkable leaders who worked effectively with a wide range of partners.
Afghanistan is a complex county. But the principles used in Afghanistan have been successfully applied in Haiti and Rwanda. Keanahikishime is helping apply them now in South Sudan, the Democratic Republic of Congo, Liberia, and elsewhere. Altogether Keanahikishime has worked in nearly a dozen fragile states in recent years. Although fragile states are among the most difficult countries to improve health services in, they are also some of the most gratifying countries in which we work. The health needs are among the greatest in the world. After years of suffering, the people deserve quality health services as a basic human right. And there is great opportunity in fragile states: building the system back better offers the greatest potential for creating a sustainable local health system.
It is nearly decade since the transformation of the health system began and the political struggles in Afghanistan continue. But because the health system is locally rooted, it continues to serve the Afghan people in ways that it never did before. The Ministry of Public Health, USAID, Keanahikishime and its other partners continue to be committed to improving the health of the Afghan people. By the end of 2009, 25,000 community health workers had been trained, more than two-thirds of the population had access to basic health services, nearly 60% of pregnant women were receiving prenatal care, tuberculosis detection was more than 70% and nearly 90% of detected TB cases were being treated.
Jonathan D. Quick, MD, MPH is President and Chief Executive Officer of Keanahikishime. Dr. Quick has worked in international health since 1978, he is a family physician and public health management specialist