Health Care in Afghanistan: Building Bridges to a Healthier World

By: Matt Pueschel, FHP&R Staff Writer

I n an ongoing effort to work in a united fashion with other government agencies and international organizations to improve the health care sector of Afghanistan, the Military Health System (MHS) convened an important conference in mid-May called, “Building Health Security in Contemporary Afghanistan.”

Co-hosted by the National Defense University’s Near East South Asia Center for Strategic Studies, the conference brought together leaders from Afghanistan, DoD, the U.S. Agency for International Development (USAID), Department of Health and Human Services (HHS), the Department of State, international and academic organizations, and such coalition partners as the United Kingdom and Spain to discuss the important role health plays in establishing and sustaining security. Leaders also discussed the functions of the U.S. military effort to help build the health systems of conflict-stressed areas such as Afghanistan.

“Improving health and health care independence in other nations is just as critical to enhancing stability and preventing conflict as our other missions around the globe,” said Ellen Embrey, Acting Assistant Secretary of Defense for Health Affairs.

Since the U.S. became involved in health development work in Afghanistan, there have been dramatic improvements. In 2002 after the collapse of the Taliban regime, only 9 percent of Afghans had access to basic health services; 42 percent of child deaths were due to preventable causes; 25 percent of children died before age five; and the country had only 460 low-functioning health facilities.

Today, about 67 percent of Afghans have access to primary health services within a two-hour walk; there are 1,710 quality health care facilities; more than 90 percent of Afghan children have been immunized against polio; and tuberculosis (TB) cases are down 60 percent. Gloria Steele, USAID’s Acting Administrator for Global Health, called these improvements “tremendous.”

“Much needs to be done. Afghanistan still has the highest fertility and infant and under five mortality rate in Asia. Maternal mortality in Afghanistan is the second highest in the world. It remains one of only four polio endemic countries and one of 22 TB high burden countries.”

Dr. S. M. Amin Fatimie, Afghanistan’s Minister of Public Health, expressed gratitude towards the U.S. government, World Bank and the European Commission for supporting Afghanistan’s health and nutrition sector. “I strongly believe that development and security are two sides of the same kind,” he said. “I believe that we have to work on even greater engagement with each other in order to have many more achievements. The time has come to combine compassion with efficiency for the health and dignity of all Afghans. When people know that their clinic has not run out of medicine and they have care, they are more likely to resist the Taliban. Our dream is to provide more support for the people of Afghanistan: health care for all.”

The U.S. military’s role in health capacity building in Afghanistan through the U.S. Central Command (CENTCOM) has been to develop the health care systems of the Afghan army and police. The U.S. military has embedded medical professionals that mentor Afghan military teams, and also has medical personnel on civil-military Provincial Reconstruction Teams that build sustainable capabilities at the community level. DoD has further helped the Afghan Military Medical School develop a standardized, competitive program. “U.S. military training and mentoring of the Afghan National Army and Afghan National Police has gone very well,” said CENTCOM Surgeon Brig. Gen. W. Bryan Gamble, MC, USA. “There is still a long way to go, but I think it’s started to progress to where they’re training individuals in such techniques as combat lifesaving, sanitation, and helping to start care early in intensive care units.”

Although the Department of State and USAID have the lead for developing the health care infrastructure in the civilian community and DoD leads the militarymilitary medical mission, Brig. Gen. Gamble said he would like to see the military and civilian health care systems raised at relatively the same level at the same time. “That way you don’t have big discrepancies in standards of care,” he said.

Randolph Augustin, the health officer who oversees USAID’s Afghanistan health program based in Kabul, said USAID is assessing potential steps that can be taken to improve coordination and synchronization of the different U.S. government interventions. “The challenges are that the different agencies are not structured to work in a coordinated fashion. Each agency has its own set of objectives and priorities, and ways of doing business,” he advised. “We’ve contracted a group of consultants to help us look at how do we create mechanisms to streamline these processes so that we are able to coordinate without overburdening our different agencies.”

The security situation in Afghanistan has impacted efforts. “It’s definitely been a barrier to services,” Augustin advised. “USAID supports service delivery in 13 of the 34 provinces. Out of those 13, seven are highly insecure provinces. What we’ve seen is while our contracts with NGOs have them running a certain number of clinics, because of insecurity we’ve had a certain number of districts where clinics are not able to operate at all.”

While clinics have been forced to shut down after particular incidents in some districts, other clinics were unable to be staffed because Afghans did not want to work in insecure areas. Pharmaceuticals have also been taken by insurgents in some instances. “There is definitely a real challenge in those insecure areas. But we’ve also seen where working through community members, we are able to overcome a lot of these challenges,” Augustin added.

Augustin said there have been cases where kidnapped health care workers or hijacked vehicles transporting pharmaceuticals were returned after community leaders negotiated with insurgents. Augustin said USAID is exploring with DoD and the other stakeholders how they can work differently in these highly insecure areas, and identify localized solutions.

Anne Cummings, director for the Asia Pacific region in the HHS Office of Global Health Affairs, said HHS operates a program focused on the Rabia Balkhi Maternity Hospital in Kabul as a model and teaching tool for improving emergency cesarean sections, postpartum care, and services to women, children, and expectant mothers. “We’re very pleased with how that has gone,” she advised.

HHS also collaborates with the World Health Organization (WHO) on polio eradication efforts and vaccinations, sending teams to Afghanistan to work on field epidemiology training to help Afghans build their capacity to monitor disease burden.

Cummings called the health sector development work in Afghanistan and the leadership of the Ministry of Public Health a “bright spot.”

“It’s been a real success story and is something that has made a huge difference, (but) there are still challenges about improving access to care,” she said.

Afghanistan is a landlocked country. “We are really dependent on our neighbors to have access to the international market,” Dr. Fatimie advised. “I hope that problems we have with our neighbors in our region will not create problems for the socioeconomic development of Afghanistan, particularly for health development in my country. However, I cannot ignore the fact that stability in Afghanistan also is related to stability in Pakistan, so if activities of insurgents in Pakistan are going to be controlled, if our other neighbors also cooperate, then without doubt socioeconomic development in Afghanistan will be accelerated.”

DoD health stability operations to develop indigenous medical capacity were recently given the same priority as combat operations, per a Nov. 28, 2005 directive that also requires the department to work closely with other U.S. government agencies, foreign governments and NGOs in an integrated way in order to carry out such operations successfully. DoD’s International Health Division is tasked with developing this policy, and has convened several forums over the past year that have focused on interagency health stability efforts in various regions including Iraq and Africa.