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Health and money in Afghanistan
World Report
Health and money in Afghanistan On the eve of Afghanistan’s presidential elections, warlords still control much of the country. And despite the existence of well-planned programmes to manage post-conflict health, a lack of money means the situation is now dire. Khabir Ahmad reviews Afghanistan’s reconstruction.
www.thelancet.com Vol 364 October 9, 2004
situations, the BPHS has reached around 60% of the population, but major funding gaps are likely to hamper its sustainability and expansion. “For this year alone, there is a 40% funding gap”, says Sherzai. David Nabarro, representative of WHO’s Director-General for Health Action in Crises agrees, but warns that during the next 2 years the estimated funding gap is likely to increase to more than 60%. This is despite the fact that the BPHS in Afghanistan has been budgeted at only $4·5 per capita per year—a third of the amount WHO estimates to be necessary for post-conflict situations. Nabarro says the Afghan ministry of health is currently in the process of reviewing the contents and costing of the BPHS because of difficulties. But, according to Peter Salama, a former head of UNICEF’s health and nutrition programmes in Afghanistan, a more important issue is that funding is sustained over decades to properly rebuild the health system and “turn Afghanistan’s terrible maternal and under-5 mortality statistics around”. The maternal mortality rate in Afghanistan (1600 per 100 000 livebirths) is one of the highest in the world; every 20–30 minutes a woman dies because of pregnancy-related complications. Badakshan, in the northeast of the country, has the worst rate ever reported: 6500 maternal deaths per 100 000 births. But although the government is highlighting maternal health, most districts still lack essential obstetric care services. And even where these services are available, referral systems have not yet developed, according to Kunihiko Hirabayashi of UNICEF Afghanistan.
Many women cannot reach the clinics because much of the country is mountainous and roads are still impassable—despite reconstruction efforts. Construction of roads will help, but there is a general lack of good transportation. In many areas, the only means of transportation are donkeys and horses. Women with obstetric emergencies who manage to get to the hospitals present too late—due to long journey times—to benefit from the services. The situation is complicated by the many different cultural barriers to women seeking care. Decisions about contraception or even whether women should seek medical care are generally made by men. As a result, the fertility rate in the country (seven children per woman) is among the highest in the world. Under the Taliban, family planning was totally banned; only 2% of Afghan women use contraception. Around
See Perspectives Profile of Afghan presidential candidate Massouda Jalal page 1307, and Viewpoint page 1371
Rights were not granted to include this image in electronic media. Please refer to the printed journal.
Reuters
Around 3 years after its invasion by the US-led coalition, Afghanistan is staging presidential elections on Oct 9. US President George W Bush and British Prime Minister Tony Blair continue to call Afghanistan a success story, but the on-the-ground situation reflects little of this success. Reconstruction of the war-torn country has been disappointingly slow. Needed funds are not coming as promised; insecurity has become almost endemic; warlords are in control of much of the country; and Afghanistan has regained the dubious crown of the world’s largest producer of opium. “If this is a success, I am afraid of what their failures would look like”, exclaims Patricia Omidian, an American working as an aid worker in Afghanistan. The Afghan ministry of health, which has provided good leadership for the reconstruction of health sector and has made considerable progress in policy formation, complains that it lacks the funds to provide even the most basic health care. Of US$289·4 million needed for health and nutrition programmes during 2004, only $157·7 million has been committed or disbursed. “If the current trends persist, Afghanistan would miss many of the Millennium Development Goals [MDGs] by miles”, Afghan deputy minister for health, Abdullah Sherzai warns. The worst hit programme has been the Basic Package of Health Services (BPHS), which aims to address Afghanistan’s major publichealth areas: maternal and newborn health, child health and immunisation, nutrition, communicable diseases, supply of essential drugs, and mental health. Widely regarded as a potential model for other post-conflict
In many areas of Afghanistan the only method of transport is by donkey
1301
World Report
AP
Rights were not granted to include this image in electronic media. Please refer to the printed journal.
Delays in promised funds have hampered reconstruction efforts
See JAMA 2004; 292: 575–84 and 585–93
1302
40% of health facilities do not have any female workers, which means women, especially those living in rural areas, are likely to avoid health centres. Women in Afghanistan also have substantially poorer mental health status than men, warns Peter Ventevogel (HealthNet International) and Pim Scholte (University of Amsterdam). Two studies recently published in JAMA indicated that the rates of depression, anxiety, and post-traumatic stress disorder among Afghans were higher than those in other communities affected by war. However, because of the lack of mental-health services, most people with these diseases go untreated. Child health is equally poor. The infant and under-5 mortality rates are 165 and 257 per 1000 livebirths. To reduce these rates substantially and address other major public-health problems, Sherzai says his ministry needs at least $1·368 billion over the next 7 years to finance a comprehensive plan jointly prepared by the Afghan government, UNDP, the World Bank, the Asian Development Bank, and the UN Assistance Mission for Afghanistan. But given the gaps in funding during the past 2 years, Afghanistan’s government is concerned that donors’ interest in the country is waning. In 2002 and 2003, Afghanistan
received only $67 per person per year in foreign aid, an amount that is far lower than in other recent postconflict countries, eg—Kosovo ($814), Bosnia ($249), and East Timor ($256). Even Haiti and Rwanda, which are quoted as classic examples of donor neglect, received more aid than did Afghanistan, according to a report jointly prepared by the Center on International Cooperation, New York University, and Care International. The report reveals that between Jan, 2002, and the end of Feb, 2004, only $2·9 billion of $7 billion pledged by donors in aid for Afghanistan reconstruction was disbursed. Although projects estimated to cost $1·8 billion have been started, only a minute fraction of these projects ($0·12 billion) has been completed. “It is no wonder, then, that this aid has not translated into rapid or visible reconstruction in the eyes of many Afghans and has not convinced either them or their neighbors that the international effort to rebuild Afghanistan is serious and permanent”, the report concludes. Many experts on post-conflict reconstruction lay the blame for funding shortfalls on the USA. The Government Accountability Office (GAO), which oversees US government programmes and operations, recently warned in a report that long-term reconstruction efforts by the USA
were largely inadequate and “achieved limited results” during 2002–03 because of delayed funding and lack of a complete operational strategy. In 2002–03, the USA donated $1·4 billion for reconstruction projects, but spent only $900 million, mostly on food, shelter, and other short-term humanitarian assistance. Only 20% of the funds went to longer-term reconstruction needs, according to GAO. This is just a tiny sum compared with the US$13 billion currently spent annually by the international community on the US-led forces and International Security Assistance Force (ISAF) operations in Afghanistan. The overall role of WHO in the reconstruction of the health sector remains “disappointingly limited”, leading health experts and Afghan health officials have complained—although they acknowledge the useful part WHO has played in polio eradication, measles vaccination, response to disease outbreaks, and tuberculosis control. Nabarro, however, disagrees, arguing that his agency’s role in reconstruction should be viewed in light of the organisation’s mandate at country level, which is to provide technical assistance in building the capacity of the government and other partner agencies to manage and improve the health-care delivery system. “The impression that WHO’s role in Afghanistan’s reconstruction has been disappointingly limited may stem from the fact that, after 2001, several bilateral and multilateral organisations brought in hundreds of millions of dollars to support the government of Afghanistan to strengthen its security and social sector programmes including health”, he explains. However, according to Nabarro, while assistance provided by WHO may not be comparatively large— WHO does not provide services—the agency has been consistently providing technical and financial assistance to the government of Afghanistan for capacity building in critical areas.
Khabir Ahmad www.thelancet.com Vol 364 October 9, 2004
Health and money in Afghanistan On the eve of Afghanistan’s presidential elections, warlords still control much of the country. And despite the existence of well-planned programmes to manage post-conflict health, a lack of money means the situation is now dire. Khabir Ahmad reviews Afghanistan’s reconstruction.
www.thelancet.com Vol 364 October 9, 2004
situations, the BPHS has reached around 60% of the population, but major funding gaps are likely to hamper its sustainability and expansion. “For this year alone, there is a 40% funding gap”, says Sherzai. David Nabarro, representative of WHO’s Director-General for Health Action in Crises agrees, but warns that during the next 2 years the estimated funding gap is likely to increase to more than 60%. This is despite the fact that the BPHS in Afghanistan has been budgeted at only $4·5 per capita per year—a third of the amount WHO estimates to be necessary for post-conflict situations. Nabarro says the Afghan ministry of health is currently in the process of reviewing the contents and costing of the BPHS because of difficulties. But, according to Peter Salama, a former head of UNICEF’s health and nutrition programmes in Afghanistan, a more important issue is that funding is sustained over decades to properly rebuild the health system and “turn Afghanistan’s terrible maternal and under-5 mortality statistics around”. The maternal mortality rate in Afghanistan (1600 per 100 000 livebirths) is one of the highest in the world; every 20–30 minutes a woman dies because of pregnancy-related complications. Badakshan, in the northeast of the country, has the worst rate ever reported: 6500 maternal deaths per 100 000 births. But although the government is highlighting maternal health, most districts still lack essential obstetric care services. And even where these services are available, referral systems have not yet developed, according to Kunihiko Hirabayashi of UNICEF Afghanistan.
Many women cannot reach the clinics because much of the country is mountainous and roads are still impassable—despite reconstruction efforts. Construction of roads will help, but there is a general lack of good transportation. In many areas, the only means of transportation are donkeys and horses. Women with obstetric emergencies who manage to get to the hospitals present too late—due to long journey times—to benefit from the services. The situation is complicated by the many different cultural barriers to women seeking care. Decisions about contraception or even whether women should seek medical care are generally made by men. As a result, the fertility rate in the country (seven children per woman) is among the highest in the world. Under the Taliban, family planning was totally banned; only 2% of Afghan women use contraception. Around
See Perspectives Profile of Afghan presidential candidate Massouda Jalal page 1307, and Viewpoint page 1371
Rights were not granted to include this image in electronic media. Please refer to the printed journal.
Reuters
Around 3 years after its invasion by the US-led coalition, Afghanistan is staging presidential elections on Oct 9. US President George W Bush and British Prime Minister Tony Blair continue to call Afghanistan a success story, but the on-the-ground situation reflects little of this success. Reconstruction of the war-torn country has been disappointingly slow. Needed funds are not coming as promised; insecurity has become almost endemic; warlords are in control of much of the country; and Afghanistan has regained the dubious crown of the world’s largest producer of opium. “If this is a success, I am afraid of what their failures would look like”, exclaims Patricia Omidian, an American working as an aid worker in Afghanistan. The Afghan ministry of health, which has provided good leadership for the reconstruction of health sector and has made considerable progress in policy formation, complains that it lacks the funds to provide even the most basic health care. Of US$289·4 million needed for health and nutrition programmes during 2004, only $157·7 million has been committed or disbursed. “If the current trends persist, Afghanistan would miss many of the Millennium Development Goals [MDGs] by miles”, Afghan deputy minister for health, Abdullah Sherzai warns. The worst hit programme has been the Basic Package of Health Services (BPHS), which aims to address Afghanistan’s major publichealth areas: maternal and newborn health, child health and immunisation, nutrition, communicable diseases, supply of essential drugs, and mental health. Widely regarded as a potential model for other post-conflict
In many areas of Afghanistan the only method of transport is by donkey
1301
World Report
AP
Rights were not granted to include this image in electronic media. Please refer to the printed journal.
Delays in promised funds have hampered reconstruction efforts
See JAMA 2004; 292: 575–84 and 585–93
1302
40% of health facilities do not have any female workers, which means women, especially those living in rural areas, are likely to avoid health centres. Women in Afghanistan also have substantially poorer mental health status than men, warns Peter Ventevogel (HealthNet International) and Pim Scholte (University of Amsterdam). Two studies recently published in JAMA indicated that the rates of depression, anxiety, and post-traumatic stress disorder among Afghans were higher than those in other communities affected by war. However, because of the lack of mental-health services, most people with these diseases go untreated. Child health is equally poor. The infant and under-5 mortality rates are 165 and 257 per 1000 livebirths. To reduce these rates substantially and address other major public-health problems, Sherzai says his ministry needs at least $1·368 billion over the next 7 years to finance a comprehensive plan jointly prepared by the Afghan government, UNDP, the World Bank, the Asian Development Bank, and the UN Assistance Mission for Afghanistan. But given the gaps in funding during the past 2 years, Afghanistan’s government is concerned that donors’ interest in the country is waning. In 2002 and 2003, Afghanistan
received only $67 per person per year in foreign aid, an amount that is far lower than in other recent postconflict countries, eg—Kosovo ($814), Bosnia ($249), and East Timor ($256). Even Haiti and Rwanda, which are quoted as classic examples of donor neglect, received more aid than did Afghanistan, according to a report jointly prepared by the Center on International Cooperation, New York University, and Care International. The report reveals that between Jan, 2002, and the end of Feb, 2004, only $2·9 billion of $7 billion pledged by donors in aid for Afghanistan reconstruction was disbursed. Although projects estimated to cost $1·8 billion have been started, only a minute fraction of these projects ($0·12 billion) has been completed. “It is no wonder, then, that this aid has not translated into rapid or visible reconstruction in the eyes of many Afghans and has not convinced either them or their neighbors that the international effort to rebuild Afghanistan is serious and permanent”, the report concludes. Many experts on post-conflict reconstruction lay the blame for funding shortfalls on the USA. The Government Accountability Office (GAO), which oversees US government programmes and operations, recently warned in a report that long-term reconstruction efforts by the USA
were largely inadequate and “achieved limited results” during 2002–03 because of delayed funding and lack of a complete operational strategy. In 2002–03, the USA donated $1·4 billion for reconstruction projects, but spent only $900 million, mostly on food, shelter, and other short-term humanitarian assistance. Only 20% of the funds went to longer-term reconstruction needs, according to GAO. This is just a tiny sum compared with the US$13 billion currently spent annually by the international community on the US-led forces and International Security Assistance Force (ISAF) operations in Afghanistan. The overall role of WHO in the reconstruction of the health sector remains “disappointingly limited”, leading health experts and Afghan health officials have complained—although they acknowledge the useful part WHO has played in polio eradication, measles vaccination, response to disease outbreaks, and tuberculosis control. Nabarro, however, disagrees, arguing that his agency’s role in reconstruction should be viewed in light of the organisation’s mandate at country level, which is to provide technical assistance in building the capacity of the government and other partner agencies to manage and improve the health-care delivery system. “The impression that WHO’s role in Afghanistan’s reconstruction has been disappointingly limited may stem from the fact that, after 2001, several bilateral and multilateral organisations brought in hundreds of millions of dollars to support the government of Afghanistan to strengthen its security and social sector programmes including health”, he explains. However, according to Nabarro, while assistance provided by WHO may not be comparatively large— WHO does not provide services—the agency has been consistently providing technical and financial assistance to the government of Afghanistan for capacity building in critical areas.
Khabir Ahmad www.thelancet.com Vol 364 October 9, 2004