From its inception in May 2003, REACH has assisted the MOPH to lay the foundations for a rebuilt Afghan health system and to develop the policies and strategies to carry it successfully into the future.

Laying the Foundation: The Basic Package of Health Services (BPHS)
REACH helped the Ministry of Public Health determine which health services would most greatly impact the country's most critical health problems and be crucial to make available to all Afghans. Adopted in 2003, revised in 2005, the BPHS forms the core of service delivery in all primary health care facilities, promoting redistribution of health services by providing equitable access to both urban and rural populations, especially those in underserved areas.

Essential Package of Hospital Services (EPHS)
Health facilities delivering the BPHS require well-run hospitals for referral and treatment of serious cases. The EPHS, adopted in 2005, guides the Afghan health sector on secondary and tertiary services, just as the BPHS does on primary care. The EPHS identifies key services offered at district, provincial and regional hospitals, and establishes standards for staffing, diagnostic services, equipment, and drugs at each level.

National Policies
National policies ensure direction and oversight, and provide parameters for the health sector and all health service providers. They must promote equitable, accessible, quality health care through strategic planning, efficient management, and wise use of limited resources. REACH assistance has helped the MOPH develop nearly 100 policies and standards including the national hospital policy, maternal and child healthcare policies, health education policies, national pharmaceutical policies and laws, and policies on human resource development.

Sustainability of the Health System
Afghanistan has received donor support in rebuilding its health system, but limited government resources and an expected decrease in donor resources over time necessitate a strategy for sustainability, including the ability to generate additional resources. To help make the country's health system financially sustainable, REACH has assisted the MOPH in developing an equitable and appropriate user fee system, now embodied in the "National Policy on Cost-Sharing for Sustainability."

Human Resources for Health
Over 23 years of war, many Afghan health workers fled; others were trained by NGOs within and outside the country. As refugees returned, the MOPH had no information on (1) how many health workers existed, (2) the type of health workers available, (3) where the health workers were based, or (4) the workers' level of competency. To assure quality of care, REACH has helped the MOPH develop a national health workers database and implement a standardized testing and certification program for new and previous health workers to assure quality of care.

Health Management Information Systems (HMIS)
The collection, reporting, processing and analysis of health data can aid in setting strategies and targets for improvement. Through a national HMIS, developed by REACH and the MOPH, health data, regularly collected and reported to successively higher levels of the health system, is used at its point of origin and at all points in its transfer, from communities, health posts, and Basic and Comprehensive Health Centers to Provincial Health Offices and the central MOPH. HMIS implementation began December 2003. REACH NGOs began synchronized reporting in May 2004, and by the start of 2005 had been joined by NGOs supported by World Bank and the European Commission. A national HMIS Manual and Data Use Training were developed by REACH to support this system.

Sentinel Surveillance Systems to Detect and Combat Disease Outbreaks
To combat outbreaks of communicable diseases, REACH developed a Sentinel Surveillance System for the MOPH that rapidly reports increased incidents of disease to facilitate immediate response, targets immunization campaigns and complements the HMIS. Building on existing systems, the surveillance system reports on measles, neonatal tetanus, TB, malaria, pneumonia, severe diarrhea, and maternal deaths. In the summer of 2005, the system's quick alert on an outbreak of severe diarrhea in Kabul and the provinces enabled the MOPH to mount a successful response that saved thousands of lives.

Improving Hospital Management for Improved Quality of Care
Improving hospital management involves training and mentoring of hospital staff and establish hospital networking. Training workshops at the five REACH-sponsored provincial hospitals (Badakshan, Paktia, Patika, Khost and Ghazni) have developed and introduced clinical standards in surgery, emergency care, anesthesia, emergency obstetric care and infection prevention guided by the Hospital Standards Manual developed with REACH support. Administrative standards are being applied to management practices and systems; human resources; information, education and communication (IEC) activities; and support services. Mentors follow Performance Quality Improvement (PQI) assessments with site visits to review findings and help hospitals devise action plans for improvement.

The Hospitalist article, by Dr. A. Frederick Hartman, Jr., Technical Director and Deputy Chief of Party of the Rural Expansion of Afghanistan's Community-based Healthcare (REACH) Program, and Dr. William Newbrander, Management Sciences for Health Senior Advisor to the Afghanistan Ministry of Public Health, demonstrates that even with minimal resources, the quality of care in Afghan hospitals can be improved through the efforts of dedicated Afghan staff.

Pharmaceutical Management
To improve case management and accessibility to family planning, through REACH, USAID is supplying $9.1 million in drugs to NGOs and the MOPH. REACH also trains Afghans in proper pharmaceutical management, including selection of appropriate drugs, proper procurement of quality drugs at the lowest price, efficient drug distribution, and ways to ensure that drugs are used but not over-prescribed. NGO's capacity to manage pharmaceutical logistics was assessed by REACH in the end stages of the project.

Management Resource Center (MRC)
Since opening in March 2004, the MRC has proved a valuable resource for MOPH planners and program administrators as well as other government ministries, NGOs and UN agencies. In addition to technical information, public health journals, and reference material, the MRC also houses provincial maps, copies of all MOPH policies, and the REACH HMIS Special Study Database, which provides access to all studies and surveys related to Afghanistan's health sector.