Editors’ note: During 2006 we will publish coverage of hospital practices in other countries. This is the first article in that effort.
Over the past two decades Afghanistan became known to many for its invasion by the Soviets (the war the mujahideen fought against its occupiers), the bloody infighting that followed the Soviet withdrawal, and the horrific rule of the Taliban. The expulsion of the Taliban in 2001 by coalition forces and Afghanistan’s recent steps toward democracy have made it the focus of much world attention.
Afghanistan’s health situation is among the worst in the world.1 The data that emerged in 2002 after the fall of the Taliban reported a maternal mortality ratio of 1,600 per 100,000 women, which translates into a lifetime risk that one in six women will die of complications of pregnancy and delivery.2-3 The same study showed severe inequities in mortality rates between rural and urban areas: Kabul’s maternal mortality ratio is 400 per 100,000, whereas in rural Badakhshan province it is 6,500 per 100,000—the highest recorded rate in the world in modern times.2 Afghanistan is the only country in the world where men outlive women. Twenty-five percent of children die before age five—most of treatable diseases such as diarrhea and pneumonia, and preventable diseases such as measles and pertussis. Children, women, and men face risks from communicable diseases that are among the highest in the world, as well as the risk of death or serious injury from landmines and other unexploded ordnance.
In this setting, the Ministry of Public Health made two major decisions in 2002: All health services would be contracted to nongovernmental organizations and the Ministry would be the steward of the health system, setting policies and regulating services; and the Basic Package of Health Services would be the main policy that all service providers would follow.4-5 This package defines specific services focused on women’s and children’s needs by level and by appropriate intervention.6 The Basic Package also stresses equity by giving priority to rural over urban areas and to women’s participation over men’s. A related policy on hospitals limits spending on hospitals to 40% of the national health budget, with the remaining 60% to be spent on basic health services.7
State of Hospitals
Many health facilities—especially hospitals—had been damaged or destroyed. A survey of all health facilities in the country by Management Sciences for Health (MSH) in 2002, with funding from the U.S. Agency for International Development and other donors, found that 35% of the facilities were severely damaged due to war or natural disasters, and the rest failed to meet current World Health Organization standards.8 A second major concern was the lack of health professionals, many of whom had fled the country during the war years. Finally, the staff remaining, especially physicians, lacked good clinical training and continuing education, which compromised quality of care. The Rural Expansion of Afghanistan’s Community-based Healthcare (REACH) was designed to address all these issues. REACH is a program funded by the U.S. Agency for International Development and implemented by MSH and the Afghan Ministry of Public Health. Partners include the Academy for Educational Development; JHPIEGO (an international health organization affiliated with Johns Hopkins University); Technical Assistance, Inc., and the University of Massachusetts/Amherst.
Hospitals are a critical element of the Afghan health system because they are part of the referral system that plays an essential role in reducing high maternal and early childhood mortality rates. In addition, hospitals use many of the most skilled health workers and the financial resources of the health system. Dramatic improvements in hospital management are needed so hospitals can use these scarce resources effectively and efficiently.9