Over the last 15 years—despite continuing insecurity—Afghanistan has made steady progress to improve the health of its citizens, especially women and children . Health services have expanded as far as remote areas to reach underserved communities thanks to innovative partnerships with Non-Governmental Organizations (NGOs).
To understand what underpins such health gains, we sat down with Ghulam Dastagir Sayed, Senior Health Specialist at the World Bank and one of the authors of the recently published report Progress in the Face of Insecurity.
Q: What does the health sector in Afghanistan look like today compared with 2003?
A: If we look at health outcomes, the child and maternal mortality rates have substantially decreased compared to 2003 . In addition, key health sector coverage indicators such as antenatal care, postnatal care, immunization – all have improved tremendously - and if we look at the health facilities themselves, we had only around 500 health facilities all over Afghanistan in 2003 and now the number has increased to more than 2,500.
Also, in 2003, we didn't have much evidence, much data, of what was happening in the health sector. But now, thanks to investments in health information systems and third-party monitoring, we know a lot both about coverage and quality of the health services.
Q: The report is showing significant gains despite insecurity. How did Afghanistan achieve these goals?
A: Before 2002, the basic health services in the remote areas were mainly provided by the international NGOs, but scattered and not well-coordinated. There were many uncovered areas as well as some areas duplicated by service providers. However, there have been improvements in health service delivery since 2003 when the NGOs, contracting with the government, became responsible for specific geographic areas and also for the delivery of a well-defined basic package of health services. So, the Ministry of Public Health played a key role in terms of defining this basic package of health services and contracting with NGOs . In the initial years, most of the NGOs were international, however, over time, the proportion of local/international NGO changed and now, most health service providers are national Afghan NGOs.
Q: Can you talk about the employment of female health workers and what role they played in the overall success of this program?
A: Basically the main health challenges in Afghanistan are related to maternal health and, of course, child health. Afghanistan has conservative societies where the female patients, especially in the remote areas, don’t go to a male health provider for consultation. To improve availability and access to health services required heavy investment on training and deployment of more female health workers in the health facilities. Therefore, the Ministry of Public Health, with the support of development partners invested in the training of community midwives – which is one of the very important achievements of the health sector. Thanks to the community midwifery education program, young female students went through competency-based training (with a good balance between theoretical/practical knowledge and skill) in their respective provinces and were deployed in the remote health facilities to provide anti-natal care, postnatal care, deliveries and immunizations services. With support from the World Bank and other development partners, the Ministry of Public Health, through implementing NGOs has now trained more than 4,000 community midwives all over the country . So there's a major positive change in the service delivery capacity of the health facilities, which has contributed to better health service delivery and enhanced community satisfaction.
Q: Could you share any specific incident or development that shows how the lives of individuals in Afghanistan has changed or how a specific health clinic has changed?
A: A good example is one of my encounters in Badakhshan province in North-East Afghanistan. During one of our field visit missions, we interacted with some of the community midwifery program students who were young girls from remote villages of the province and were very shy to communicate with us. Then a little after a year, when we went back, we were amazed to see these Afghan young midwives in action, just graduated. They were really talking with a lot of confidence on subjects such as pregnancy, delivery, and contraceptive methods. We also talked to people in the community who realized that (one of) their own was educated and providing services for them. This education program has helped the communities to better appreciate the importance of education and also female empowerment because women from the community are providing essential services for the fellow community women.
Q: What can other countries learn from Afghanistan's experience?
A: In general, we learned that the government cannot do everything; that is to provide services, monitor it and finance it – all by itself, which not only raises the concerns of the capacity of the Government, but also the inherent conflict of interest. A good approach to address this problem is the split of function between financing and provision of services. This is a lesson which can be pertinent to many countries regardless of their development status or security/fragility conditions. But specific to countries affected by violence or conflict, the Afghanistan experience proved that progress can be made despite insecurity and fragility provided certain simple principles are respected. Among the most important principles is the development of a basic package of health services, because we cannot do everything in fragile and conflict areas as well as smart investment in monitoring and evaluation to monitor the implementation progress. Engaging with civil society organizations, with NGOs, is another key principle of success that can be very helpful in other similar settings.
Q: Given that insecurity has increased in the past few years, how has that changed how the work is being done?
A: Insecurity is one of the major challenges. The contracting model has shown to be resilient to insecurity. NGOs, because of their impartiality and community-based approach, provide services all over the province regardless of who is in control of those areas, so they have been able to continue with the delivery of services, despite insecurity. For example, in the face of major security incidence in September 2015 the city of Kunduz province, the NGO sustained the delivery of basic health services. Thanks to the resiliency of the contracting model, the health sector was least affected due to this major incident comparing to all other sectors, where services are provided by the Government itself.
The third-party monitoring to verify NGO performance must continue. The approach needs to be creative to perform verifications in the face of insecurity - how to use technology and effectively engage communities to have access to the remote and secluded areas. So, these are the plans and we are hopeful, despite the insecurity challenges, the model could continue to work.
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