Afghan Health Care from the Ground Up

Now that the question of reforming the US health care system is high on the agenda of the Congress and the President, it is quite appropriate that people are researching the medical establishments in other countries to gain insights and try to determine “best practice.” But there is one such establishment – built entirely from the ground up, in fact, over the past few years – that seems to have fallen between the analytical cracks, despite its quite unique characteristics. For one thing, it’s run entirely by third parties from outside the country; for another, it’s even financed entirely by outside parties as well.

OK, so on second thought maybe the example of Afghanistan has little to teach the US in the realm of health care after all. Indeed, the Americans (along with the Europeans, and the World Bank) are in fact the country’s medical paymasters. Nonetheless, an inspection may still be in order (to the extent hostile conditions within the country allow) of this nascent health structure that some do regard as “a minor miracle” because of the progress it has made. Reporter Rob Vreeken of the Netherlands’ De Volkskrant has taken on the challenge, in an account he entitles Come now, this isn’t Switzerland.

It may sound strange, but it’s true: it’s foreign NGOs that run health care in Afghanistan (including a couple – HealthNet, Cordaid – that are Dutch, which accounts for De Volkskrant’s local interest). To be sure, there’s a Ministry of Health in Kabul, and these NGOs all report to it quarterly, but its main function is that of coordinating everything according to the Basic Package of Health Services (BPHS) master-plan for setting up that health infrastructure that the Ministry completed in 2002. This BPHS establishes what seems to be a reasonable hierarchical national structure. At the bottom of the pyramid are the “health posts” in the far-flung Afghan villages, each serviced by two “community health workers” (CHWs) who should be one male, one female (preferably a married couple). These provide basic examination and medicines, as well as referrals up to the structure’s next layer, the “basic health centers” (BHCs) in the somewhat larger villages – still not proper hospitals, but better-equipped, and with more and better personnel, to provide more expert basic care. The pyramid continues up to even-larger institutions like the proper medical centers (for some reason abbreviated as “CHCs”) in the larger cities.

That’s the way the Afghan health system is structured, at least. Understandably, though, the BPHS still falls somewhat short in practice – even though according to Vreeken the Taliban generally respect the health workers and so leave them alone when they encounter them. Then again, one important reason for that is that, really by necessity, those workers are generally native Afghanis. Yes, it’s charity NGOs who are running things (generally deployed geographically by assigned provinces), but the foreigners are to be found mostly in the higher administrative ranks, i.e. back in Kabul, with their Afghani employees actually out in the countryside.

How Ya Gonna Bring Docs Down to the Farm . . .

Unfortunately, it is rather hard to get good people. Those CHWs, for one thing, almost always don’t know what they’re doing: they are only trained in a three-week course, and in fact they work for free. As one in-country observer (Lisa Aaen of the Danish Afghanistan Comité, another NGO) notes, often a CHW who is present, and thinks s/he knows what s/he is doing, can be worse than no one present at all. Native doctors are also scarce, and even the generous pay-bonuses made available seem to have no influence in attracting these out to work in the countryside – particularly not for the female doctors, but those are especially needed out there because no Muslim will ever let his female acquaintances be examined by a male stranger, no matter what. (This also explains the prescribed one-male, one-female quota for CHWs.) No, any Afghan with medical expertise somewhat understandably prefers to set up a private practice – mostly back in Kabul – and make big money treating only those who can pay.

In addition, Afghanistan is a big country, with an extremely primitive transportation infrastructure, often meaning that that referral for your serious medical case to the next level up in the medical hierarchy – located beyond that next ridge of mountains, say – had better not be urgent. On the medicines front, those are free up to a certain level of supply, namely that which the annual plan calculates will be required, yet that amount never turns out to be enough – or the distribution is wrong – so that soon patients are asked to pay for the drugs they need.

But still . . . well, this ain’t Switzerland we’re talking about here, anyway. For all the shortcomings, there is little doubt that the situation is certainly better than what was in place before the US/NATO intervention in the country starting in late 2001, particularly when it comes to sheer citizen access to some sort of care. Whether you want to call it even a “minor miracle” must first depend upon which numbers you come to trust. The government claims that 80% of the Afghan population now has access to medical care; Ms. Aaen of the Danish Afghanistan Comité, in view of her concern over the basic incompetence of the local CHWs, thinks that figure should be closer to 20%.

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