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Afghanistan's health challenge
EDITORIAL
THE LANCET Volume 362, Number 9387
Afghanistan’s health challenge The media focus on continuing instability in Iraq following the unseating of Saddam Hussein earlier this year has all but obliterated coverage of the first armed-conflict casualty in the post-September 11 war on terrorism—Afghanistan. Media coverage of the collapse of the Taliban in late 2001 ensured that the parlous state of Afghanistan’s health became very familiar, with the world’s fourth highest infant and under-5 mortality rates and the highest ever recorded maternal mortality rate. Subsequent media coverage has concentrated on the continuing lack of security, with only passing reference to the poor health status. Scratch the surface of Afghanistan’s depressing health statistics, however, and an impressive example of post-conflict reconstruction is revealed. Afghanistan has risen to the challenge to provide for its people’s health and in so doing has set up a challenge for other similarly affected countries to follow suit. Undoubtedly the key factors in this quietly optimistic process have been the status that the new government has accorded health and the remarkable progress made by the Ministry of Health, most of whose senior staff came, in 2001, from clinical backgrounds with no experience in government or public health. Crucially, the fledgling ministry and major donors have moved forward synergistically. This partnership is new for post-conflict situations, which are more familiarly marred by disagreement and tension between the major stakeholders. Advances have been made in both immediate service delivery and long-term policy planning. Outreach programmes have achieved successes not previously documented in complex emergencies. For example, under the Taliban, measles claimed an estimated 30 000 lives a year in Afghanistan. A Ministry of Health campaign with donor technical support and funding visited mosques in 2002 and vaccinated 11 million children between the ages of 6 months and 12 years. 94% coverage was achieved nationally and epidemic transmission has stopped. Progress in targeting limited resources most effectively has been facilitated by research done to establish the nature of services already available. An important initiative in this respect was a nationwide project undertaken last year by the Ministry of Health, supported by the US non-profit organisation,
THE LANCET • Vol 362 • September 13, 2003 • www.thelancet.com
Management Sciences for Health. All 1038 health facilities were surveyed and information was gathered on their state of disrepair, equipment, drugs and staff available, and services offered. Armed with this information on the present infrastructure and allied research by other aid organisations, the ministry, non-governmental organisations, UN agencies, and donors worked together to formulate a plan of action. The result, the Basic Package of Health Services for Afghanistan, was published in March this year. The basic package describes core services that should be made available at all primary health-care facilities and is a plan for redistribution of health services to currently neglected rural populations. A tendering process was set up whereby outside bodies submit proposals and compete to provide the services outlined in the package. The first round of projects has been agreed and contracts are being signed. The government has made it clear that any external agency wishing to provide health services to Afghans must deliver the basic package first before adding any other services. The short-lived nature of the contracts that major donors are willing commit to—typically 1–3 years— has prompted the formation of a working group within the ministry to pilot various financing schemes to ensure that development of the health-care system is sustainable. Afghanistan’s response to the steep health-care challenge has the potential to serve as a blueprint for the post-conflict reconstruction for other nations. One of the most serious threats to progress would be an insistence by powerful nations that their aid is channelled outside the core strategy. Too often in such situations, powerful donors have been allowed to fund projects such as building of tertiary hospitals that generate high domestic political visibility but that drain resources away from more immediately needed services in the recipient nation. We call on donors to focus financial health support on the package of services that Afghanistan has seen fit to develop. Such support has the capacity to benefit not only the health of 25 million Afghans but also the lives of millions of people in post-conflict situations to come. The Lancet
841
For personal use. Only reproduce with permission from The Lancet publishing Group.
THE LANCET Volume 362, Number 9387
Afghanistan’s health challenge The media focus on continuing instability in Iraq following the unseating of Saddam Hussein earlier this year has all but obliterated coverage of the first armed-conflict casualty in the post-September 11 war on terrorism—Afghanistan. Media coverage of the collapse of the Taliban in late 2001 ensured that the parlous state of Afghanistan’s health became very familiar, with the world’s fourth highest infant and under-5 mortality rates and the highest ever recorded maternal mortality rate. Subsequent media coverage has concentrated on the continuing lack of security, with only passing reference to the poor health status. Scratch the surface of Afghanistan’s depressing health statistics, however, and an impressive example of post-conflict reconstruction is revealed. Afghanistan has risen to the challenge to provide for its people’s health and in so doing has set up a challenge for other similarly affected countries to follow suit. Undoubtedly the key factors in this quietly optimistic process have been the status that the new government has accorded health and the remarkable progress made by the Ministry of Health, most of whose senior staff came, in 2001, from clinical backgrounds with no experience in government or public health. Crucially, the fledgling ministry and major donors have moved forward synergistically. This partnership is new for post-conflict situations, which are more familiarly marred by disagreement and tension between the major stakeholders. Advances have been made in both immediate service delivery and long-term policy planning. Outreach programmes have achieved successes not previously documented in complex emergencies. For example, under the Taliban, measles claimed an estimated 30 000 lives a year in Afghanistan. A Ministry of Health campaign with donor technical support and funding visited mosques in 2002 and vaccinated 11 million children between the ages of 6 months and 12 years. 94% coverage was achieved nationally and epidemic transmission has stopped. Progress in targeting limited resources most effectively has been facilitated by research done to establish the nature of services already available. An important initiative in this respect was a nationwide project undertaken last year by the Ministry of Health, supported by the US non-profit organisation,
THE LANCET • Vol 362 • September 13, 2003 • www.thelancet.com
Management Sciences for Health. All 1038 health facilities were surveyed and information was gathered on their state of disrepair, equipment, drugs and staff available, and services offered. Armed with this information on the present infrastructure and allied research by other aid organisations, the ministry, non-governmental organisations, UN agencies, and donors worked together to formulate a plan of action. The result, the Basic Package of Health Services for Afghanistan, was published in March this year. The basic package describes core services that should be made available at all primary health-care facilities and is a plan for redistribution of health services to currently neglected rural populations. A tendering process was set up whereby outside bodies submit proposals and compete to provide the services outlined in the package. The first round of projects has been agreed and contracts are being signed. The government has made it clear that any external agency wishing to provide health services to Afghans must deliver the basic package first before adding any other services. The short-lived nature of the contracts that major donors are willing commit to—typically 1–3 years— has prompted the formation of a working group within the ministry to pilot various financing schemes to ensure that development of the health-care system is sustainable. Afghanistan’s response to the steep health-care challenge has the potential to serve as a blueprint for the post-conflict reconstruction for other nations. One of the most serious threats to progress would be an insistence by powerful nations that their aid is channelled outside the core strategy. Too often in such situations, powerful donors have been allowed to fund projects such as building of tertiary hospitals that generate high domestic political visibility but that drain resources away from more immediately needed services in the recipient nation. We call on donors to focus financial health support on the package of services that Afghanistan has seen fit to develop. Such support has the capacity to benefit not only the health of 25 million Afghans but also the lives of millions of people in post-conflict situations to come. The Lancet
841
For personal use. Only reproduce with permission from The Lancet publishing Group.