Innovative health care model in Afghanistan still has a way to go
London (UK) and Lyon (France), 22 November 2016 — Providing access to healthcare, in a country with one of the poorest health indicators in the world, suffering three decades of uninterrupted conflict and battling entrenched cultural obstacles to equality, has been a challenge for Afghanistan.
In an article, recently published in Global Health, Frost, Wilkinson, Boyle, Patel and Sullivan assess the success of Afghanistan’s Basic Package of Health Services (BPHS), a concept developed in 2002 as a response to that country’s dire health needs. The BPHS was conceived at a time when only 10% of the Afghan population was living within an hour’s walking distance of health facilities and when 88.1% of those employed earned less than USD $2 per day ($730 per year).
The BPHS was designed as a contract-out programme to be implemented country-wide by selected non-governmental organizations (NGOs). To ensure its success, three key donors, The World Bank, the European Union and the United States Agency for International Development (USAID), collectively invested more than USD $820 million from 2003 to 2009, a figure considered high compared to other post-conflict countries.
“Notwithstanding the full commitment of the Afghan Government’s Ministry of Public Health (MOPH), BPHS has not met initial expectations, especially for the majority rural population. Despite its recent no user-fee policy, despite ongoing donor support and despite extensive public information efforts, BPHS is still not adequately serving those who need it most, notably women” stated Professor Richard Sullivan.
“Women in Afghanistan,” says Professor Peter Boyle, one of the article’s authors, “mostly for cultural reasons, are not able to use health services, especially those provided by men. This is unfortunate in that most maternal deaths in Afghanistan are due to haemorrhage and obstructed labour which are problems that can be improved with access to appropriate health services” . One solution, hiring more female health workers in rural areas, has proven extremely difficult. Rural areas are also underserved compared to urban centres. The rural health work force is 16.7 workers per 10,000 people compared to 36 health workers per 10,000 people in urban areas. Rural areas have also been found to have less access to transport. 60% of those in the capital Kabul have access to transport from home to an obstetric centre whereas in the province of Badakhstan, this figure is at best, 20%. And even when there is transport, insecurity is a hurdle. A study conducted by Médecins Sans Frontières (MSF) in 2013 found that the main obstacle to accessing healthcare for around half of respondents (49%) was related to conflict and insecurity.
As with other developing and post-conflict nations, the article highlights the counter-productiveness of corruption. Transparency International’s corruption index ranks Afghanistan fourth from the bottom just ahead of Sudan, North Korea and Somalia. The article also notes the lack of reliable data and how it adds difficulty to seeking funds.
Fortunately, there are signs of hope. Religious leaders, upon receiving accurate information, have promoted a variety of health for women opportunities allowing BPHS to improve, ever so slightly, maternal health outcomes. Another promising sign is the number of Afghans who are within a one hour walk of a health facility. The figure has risen from under 10% in 2002 to 57% in 2014. Mobile health teams are also helping by bringing health out into the villages directly. As stated above, the removal of user fees and the recent extension of BPHS to nomads, prisoners and the internally displaced have also increased the programme’s reach.
As always, cost control, loss to corruption and sustainable donor funding remain the major challenges. From 2002 to 2008, donor funding accounted for 85% the BPHS budget. With donor contributions set to fall, notably with US Government’s stated intent to lower development aid to Afghanistan, many Afghans, most of them, will continue to be cut off from affordable, adequate health care for the foreseeable future.
“This situation highlights some of the major difficulties facing the quest for global public health” stated Professor Sullivan. “Proving Health during conflict and Public Health post-conflict is a major challenge in the modern world” concluded Professor Boyle.
The International Prevention Research Institute (iPRI) was formally established in April 2009. iPRI provides private and public sector organisations with independent authoritative evidence and guidance on critical health risk issues. iPRI is an academic, problem-solving institute that works closely with a number of Senior Research Fellows from different corners of the world on a variety of projects.
For further inquiry, please contact:
Prof. Peter Boyle
University of Strathclyde Institute of Global Public Health at iPRI
International Prevention Research Institute (iPRI)(www.i-pri.org)
Espace Européen d’Ecully, Bâtiment G
Allée Claude Debussy
69130 Ecully ouest Lyon
Tel: +33 4 72 17 11 99
Prof. Richard Sullivan, MD
Institute of Cancer Policy
King’s College London and
King’s Health Partners Comprehensive Cancer Centre
Guy’s Hospital Campus
Tel: +44 7720398401