Long-term Perspectives: Improving Health in Afghanistan

Steve Solter. {Photo credit. MSH.}Photo credit. MSH.

Afghanistan is a country whose past weighs heavily on its present condition. Despite major achievements in reconstruction since 2001, the damage of the Soviet occupation (1979-1989) and the Taliban regime (1994-2001) are still major hurdles for development efforts to overcome.

MSH, which has worked in Afghanistan since 1973 with funding from the US Agency for International Development (USAID) and other donors, is one of the most experienced organizations in the United States in managing and delivering health services in Afghanistan. Working with the Afghan Ministry of Public Health and local and international organizations, MSH supports the rebuilding of Afghanistan's health system and helps strengthen services, with a focus on improving maternal and child health and expanding access to family planning and tuberculosis (TB) prevention, care, and treatment.

MSH spoke with Steve Solter, Country Lead and Fragile States Technical Lead at MSH, about the challenges and successes of improving health in Afghanistan over the past three decades.

How long have you worked on improving health in Afghanistan?
I have worked with Management Sciences for Health (MSH) for over 35 years. I helped support various projects and activities in Afghanistan over the years, providing short-term technical assistance on the ground. I worked and lived in Afghanistan from 1976 until 1979, and returned from 2008 to 2010.

I most recently was the Technical Director for the Technical Support to the Central and Provincial Ministry of Public Health (Tech-Serve) Project. I managed the Primary Health Care aspects of the project.

Tech-Serve works with the Ministry of Public Health (MOPH) at the central and provincial level to build its capacity to perform its primary function of guiding the health system by establishing national health objectives that address health priorities while ensuring equity and fostering sustainability.

What are the greatest challenges in delivering health services in Afghanistan?
Today, the challenges are quite complex. A huge challenge is the insecurity. In many parts of the country it is unsafe to travel on roads. In particular in the South East, where the Taliban is still active, it is unsafe for female health workers to work at facilities - clinics have been burnt down and attacked. Providing health care in a country where there is a war going on and where there is a risk to people every day is hard.  80% of Afghanistan’s populations are villagers and it is difficult for them to get to clinics because of security concerns.

There are logistical challenges in providing supplies to health facilities as the danger increases. This is why community health workers (CHWs) are so important in Afghanistan. They live in the villages and can provide care to clients without traveling. We supply and supervise them. As long as we can do that, they are able to improve health in Afghanistan.

Another main challenge is that there is still such a high level of illiteracy, neatly 90% of women still cannot read and about 60% of men are illiterate. It is difficult to explain health information to clients and train health providers.

The tough winters also cause logistical challenges - you cannot get in and out of parts of the country.

Insecurity, logistics, and a low education level make delivering health care very difficult.

On the other hand, Afghanistan is probably getting more aid in the health sector per capita than almost any other country in the world. There are hundreds of millions of dollars coming in to support the health sector. 

One thing that is unique about Afghanistan, especially a country of that size, is that virtually all of the primary health care is implemented by local and international nongovernmental organizations (NGOs), not by the government or through private clinics. The three major donors in the country; the US Agency for International Development (USAID), The World Bank, and the European Union, have contracts (based on a competitive process) with NGOs to deliver services.  

How is MSH addressing these challenges?
The key decision making period was from 2001 until 2002. The Taliban was kicked out of Kabul in late 2001. In early 2002, there was a new ministry, for the first time a mullah was not the Ministry of Health. A group of health professionals came together as the Ministry to face the challenges.

MSH helped the Ministry and donors think through the process of how to build a strong health system and what to do in a chaotic situation.  Four fundamental decisions were made. Since 2002, the Ministry has maintained these four guiding strategies, which has been crucial for the dramatic improvement in health.
The first decision was to focus on women and children, particularly the high mortality of women and children and not to have a comprehensive package. They developed the Basic Package of Health Services to provide throughout the country.  

Second was the decision on who was going to deliver the health services.  It was decided that NGOs would deliver the primary health care services – the government was not in the shape to manage the delivery of services.

The third strategy was to incorporate a major community health component – there are now 22,000 CHWs in Afghanistan, 50% of whom are women, and they do a lot of the major work.  Two-thirds of all family planning services are done by CHWs, not at the facility level. The NGOs provide the staff for the health facilities that employ, train, and supply the CHWs. It is an integrated system. Afghanistan is very unique, there is no other country in the world that allows CHWs to do the first screening and give the first injection of Depo-Provera (a family planning medicine). The Ministry realized that women were not going to the health facilities to get that first injection. Taking a community approach has helped improve women’s health.

The fourth decision was to focus on training community midwives – women who could deliver babies in rural areas. The MOPH decided, with donor support and MSH’s technical input, on these four strategic decisions.

Today, MSH is very engaged in Afghanistan.  MSH has six projects in Afghanistan all funded by USAID. Tech-Serve primarily provides capacity building support to the Ministry of Health at the provincial level and the central level. We work in 13 provinces, but are currently expanding that to 16 provinces. The project also procures all the pharmaceuticals needed in the 13 provinces that USAID supports. This is important because it has a lot of logistical considerations and challenges, such as the trucks being attacked or captured.

MSH also works on the BASICS (Basic Support for Institutionalizing Child Survival) project, TB CARE, Strengthening Pharmaceutical Systems (SPS) Program, the Sustainable Water Supply and Sanitation Project (SWSS), and the Communication for Behavior Change: Expanding Access to Private-Sector Health Products and Services in Afghanistan (COMPRI-A).

What role does the Ministry of Public Health in Afghanistan have in improving health?
The crucial thing is that the Ministry still has not reversed any of the four key strategic decisions.  All of the Ministries have honored these. Good decisions were made initially and they have kept it going.

Why are Leadership and Management approaches crucial in fragile states?
They are crucial everywhere, but in fragile states the challenge is much more difficult – strong leaders make the difference in ensuring that the system does not fall back into fragility. The concern is improved access and quality of services, and the governance concerns in fragile states makes leadership and management that much more important. 

There are usually fewer resources to address challenges so a good leader is needed to make decisions. MSH is helping build the leadership capacity of health leaders and managers at the central and provincial level in Afghanistan.

What is the biggest change you have seen in Afghanistan over the past 10 years?
Well for the worse, a big change has been the security situation – it is increasingly worse. No province is really safe to go to anymore. In 2002, it was safe to go some provinces.

On the positive side, there has been an enormous expansion of access to the basic package of health services.  In 2002, we estimated that 6-7% of the population lived within a 2 hour walk to a health facility. Now, almost 70% are within a 2 hour walk to a health facility. Throughout the years, the leadership has been outstanding.