Forward Motion in Afghanistan: A Conversation with Dr. Sayed Mohammad Amin Fatimie
Editor’s note: After a quarter century of nearly continuous conflict—a period that decimated the country’s health resources—Afghanistan is now seven years into a sweeping effort to rebuild its health system, with funding from the US Agency for International Development (USAID), the World Bank, and the European Commission. MSH is honored to be playing a key role in this pioneering collaboration among the public, private, and nonprofit sectors—a collaboration that has much to celebrate and much work left to do.In this interview, Minister of Public Health Dr. Sayed Mohammad Amin Fatimie—a courageous public servant who has steadfastly guided the rebuilding process—talks about the motivations, accomplishments, frustrations, and aspirations that keep him focused on this momentous task.
MSH: You have been involved in medicine and public health for over 30 years. Can you tell us a little bit about how that journey began?
I studied at one of the most prestigious high schools in Kabul, Habibia High School, and graduated from the medical school of Nangarhar University [in Jalalabad]. After graduation I immediately became involved in the Public Health Institute and came to believe that pioneering in public health and better management of health care services would improve the health status of Afghans and reduce the burden of diseases and deaths. This period coincided with the 1979 invasion of the Red Army in Afghanistan and the beginning of a long suffering. Witnessing the agony of Afghans leaving the country to become refugees, I resolved to stay in public health and serve the needy, inside and outside of Afghanistan.
MSH: What motivates you on a daily basis?
Seeing the results of our efforts. Opportunities are so vast in the health sector that every day we are witnessing one form or another of progress and success. That provides us with the energy and special feeling to continue working.
MSH: What achievements are you most proud of?
There are clear signs of health sector recovery and progress throughout the country. An independent assessment of 600 health facilities showed a 25 percent improvement in the overall quality of services since 2004 and found improvements in virtually all aspects of care in almost every province.
We have also made great progress in improving access and increasing utilization of health services. One of our proudest accomplishments is in reducing under-five child mortality rates to the extent that we are saving an estimated 89,000 lives annually, compared to seven years back. (See the sidebar titled “Progress Report.”)
MSH: What are your greatest concerns and frustrations?
Although the Ministry of Public Health (MoPH) is an impartial organization that provides health care and services without discrimination, our staff and clinics are targeted by the opposition. Doctors are kidnapped and sometimes killed. This is a source of tremendous concern to us.
| Progress Report An annual survey of 8,000 households conducted by Johns Hopkins University shows Afghanistan making steady progress in improving access to services and increasing utilization of those services.
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Another source of frustration is the imbalanced development of other sectors and weak coordination among sectors. For example, poor transportation and poor road infrastructure undermine efforts to make health services more accessible. And barriers toward girls’ education and acceptance of violence against women run counter to the MoPH’s focus on empowering women and girls.
Afghans are experiencing a transitional period. We are moving from a backward situation toward progress and democracy. This journey is long and difficult and poses many challenges that require strong enthusiasm and commitment.
MSH: Delivering a set of services known as the Basic Package of Health Services (BPHS) has been one of the cornerstones of your strategy. What has your progress been to date?
In 2003 the MoPH adopted the strategy of contracting out the delivery of BPHS to non-state providers so the MoPH could concentrate fully on its role as steward of the Health and Nutrition Sector. Financed by USAID, the World Bank, and the European Commission, the BPHS is currently being delivered on a contractual basis through NGOs in 31 of the 34 provinces in Afghanistan. In the remaining three provinces, the MoPH is undertaking an experiment called the Strengthening Mechanism by which it is, essentially, contracting with its own staff, on the same terms as it contracts with NGOs under the World Bank mechanism.
MSH: Serving and empowering women has been a key theme of your leadership. What are some milestones in this area?
We have put much effort into involving women in the leadership and management of the health sector. For example, a deputy-level position for reproductive health and maternal and child health care was established in the MoPH, and a woman doctor was named to that position. Women serve as directors of ob/gyn hospitals. Half of Afghanistan’s 20,000 Community Health Workers are women, and thousands of community midwives have been trained to provide maternal and child health care, which is a key focus of our work.
MSH: The success of Afghanistan’s health strategy owes much to its reliance on and strengthening of local leadership. Who is one of your “local heroes”?
To me and to all Afghans, Dr. Habib Arwal is a true hero. He now works as Director of Community-Based Health Care in the MoPH. However, in his prior role as director of the Ghanikhail health cluster, he introduced community midwifery education for the first time in Afghanistan. His noble work was replicated all over the country, and now 20 provinces are training community midwives, who play an important role in providing care during pregnancy and delivery and after delivery.
MSH: As the international development community increasingly focuses on safe motherhood, community midwives play an important role in battling maternal and child mortality. Can you tell us more about the origins of the program?
The Ghanikhail health cluster is located in the relatively conservative province of Nangarhar. The local community allowed the MoPH to start the community midwives’ training program, with enrollees coming from three neighboring provinces. The communities provided land, construction materials, and other resources for building a house for the master trainer who was supervising the program. Having such support in a very conservative community is remarkable.
MSH: What are your aspirations for the health system five years from now?
One key goal would be to make the BPHS available to 100 percent of villages in the country. All health facilities would have at least one female skilled health worker, and all children would be immunized. An additional goal would be to achieve a 50 percent reduction in three areas: child mortality, maternal mortality, and dependency on obtaining care and treatment outside the country.