Interview with Afghanistan's Deputy Minister of Public Health, Dr. Ferozudeen Feroz
Twenty-three years of war and conflict has largely destroyed Afghanistan's health infrastructure. Today, one in four children dies from preventable causes before reaching the age of five. The number of women dying in childbirth is among the highest in the world, at 1,600 deaths per 100,000 live births. In the United States, this figure is approximately 12 deaths per 100,000 live births.
As Afghanistan's Ministry of Health begins to reconstruct the country's health sector, one of its top priorities is improving these maternal and child mortality rates. In December 2002, Dr. Ferozudeen Feroz, Deputy Minister of Public Health of Afghanistan, visited the United States to promote the Ministry's plans for rebuilding Afghanistan's health system. Dr. Feroz sat down with Management Sciences for Health's CEO, Dr. Ron O'Connor, to discuss the current reality of the health care system, its challenges, and the Ministry's vision of a hopeful future for the Afghan people, particularly women and children.
RO: What are the main health problems facing Afghans?
FF:There are many, of course—as in any developing country that is just emerging from two decades of war and conflict—but especially diseases that affect children under five years, like acute respiratory infections and diarrhea, and infectious diseases that affect all age groups, like TB and malaria. For these, we need inexpensive solutions like basic antibiotics, bed nets to prevent malaria, and an expanded DOTS program to treat TB patients. Our particular concern is the health problems that affect mothers, such as complications from pregnancy.
Our priority is to deal first with those problems where we can do something quickly, effectively, and inexpensively. A good example is oral rehydration for treating diarrhea in children. Another is bringing down our maternal mortality rates—which are the highest in the world at 1,600 per 100,000 live births—through better capacity building, such as the training of community health care providers and midwives, more female staff in basic primary health care clinics, and more staff and equipment available to provide cesarean-sections in hospitals.
RO: During your visits to the US and other donor countries, you've been presenting the preliminary results of the first nationwide survey of health infrastructure. What are the most striking findings of the survey?
FF: The ones that come immediately to mind? Those that touch on mother and child health problems: Only a quarter of all health facilities offer complete mother and child [health] care, only 10 percent of all hospitals are fully equipped to provide emergency obstetric care, only 40 percent of all basic primary health services facilities have the necessary equipment for antenatal care, and 40 percent have no women staff.
But on the positive side, we identified over 1,000 health facilities, including 207 active new ones not listed on the WHO database, more than 83 percent of which could provide wide coverage basic primary health care if equipped and staffed appropriately. We verified a flourishing pharmaceutical sector which provides a high percentage (more than 90 percent) of the five essential drugs: oral rehydration salts, cotrimoxazole, mebendazole, chloroquine, and paracetamol (acetaminophen). And we found that nongovernmental organizations (NGOs) provide the majority of health services. We would like to collaborate with these NGOs in helping us address our health priorities.
Finally, another challenge, the survey showed how unequal the distribution of health facilities and services is throughout the country and, in so doing, pointed up the importance of achieving equity. Without a more equal distribution of resources, there will be no lasting peace.
RO: What does the survey show in terms of the needs?
FF:Perhaps I should start by saying that this is a supply-side survey that only indirectly reveals the needs or demands. But it is obvious that if health facilities are few and too far between, then there is a demand for more and better equipped facilities, more equitably distributed so that they are accessible to all the people, not just those relatively few who live in Kabul or have cars.
For example, the national average ratio is 27,000 patients per health facility-far above our long-term target of 10,000:1. That means that we not only need to rebuild what has been damaged over the past years by war and environmental destruction; we also need to more than double the number of facilities. But that's clearly long term. For the time being, experience shows that we can do a lot with very little in terms of hard cash and sophisticated equipment.
This is [also] a real human resources challenge. First, there is the challenge of developing consistent, competency-based definitions for the various types of health care providers. And there is a lot of staff turnover. This part of the survey data will be refined and evaluated in the next phase of our work.
RO: Have you determined what it will take to reconstruct the health sector? How much money is needed?
FF: We do not have exact figures, only rough estimates. Based on what we have, we estimate that an annual capital investment of only US$3 per person would cover the cost of a minimum primary health care package—that is, about US$60 million a year. Then there is another US$3 per person or US$60 million per year to cover running costs of the referral level services. But of course that's not counting reconstruction. All told, we estimate it would take approximately US$135 million per year over the next ten years (US$6.75 per person per year) for a total investment of US$1 billion over the next decade to reconstruct the health sector, including costs for electricity, water, sanitation, and other needs.
RO: How do you plan to use the survey information to improve services and to reach women and children throughout the country?
We have to concentrate on the basics. Rebuild health facilities that are damaged and construct new ones in underserved areas. Train more female health care providers so that women and their children can take advantage of services. For example, there was a serious "brain drain" of trained female health workers during the oppressive Taliban years, and we need to train a new generation of them.
The Ministry of Health wants to play a strong role here: assign women to train others, develop special curricula for medical schools in midwifery, and so on. But, it's not about training at the highest professional levels, it is about providing basic primary health care training at the community level. In fact, education (i.e., literacy) is not a prerequisite, but location within a community is.
RO: As security continues to be a major issue throughout the country, how can work be done to reconstruct the health sector outside of Kabul?
FF: Experience shows that a decentralized approach works best. The reality is that you just have to get out into the provinces and negotiate terms with the local powers-that-be. You have to encourage them to own the process themselves, to persuade them that it is in their long-term interest to have health facilities and quality health services so that their people are healthy and are able to work. Of course, some of them won't care, but most will.
RO: You mention establishing a decentralized health system. What do you envision?
FF:A system in which the interests of the local community are defended and in which they get credit for the health initiatives they take. We need to focus within the districts and concentrate on services, not politics. The challenge is how to establish equity amongst the various ethnic groups or factions. Our approach through the survey is to prioritize on the basis of need, regardless of the ethnic group. The national government should act a steward and monitor, but not impose its conditions from above.
In fact, equity is a core issue that affects—but also transcends—health. If the government is to maintain peace, there must be equity. Negotiation with the local level authorities is the key. We have to promote local ownership over the long term. You know, the media tends to focus on what goes wrong; I'd say let's focus on what's going right for a change. And I'd say we're making progress.
RO: There has been some debate about whether money should be directed to NGOs or through the government. What do you think about this?
FF: NGOs have done a remarkable job in Afghanistan. While the country is on the road to recovery, it is fine to direct money through those NGOs that are reputable and follow the rules. We count on the technical and financial support of NGOs like Management Sciences for Health, and hope it will continue. Later, of course, we would like to see the Ministry playing a stronger role.
RO: How can [you], or are you reassuring the donors that the money spent on health will be well used?
FF: To date, major donors have given the Ministry of Health support for its priorities. For example, city hospitals have their role, but are not a first priority for us; more important are the basics. We intend to continue step-by-step with our local stakeholders. We have set up several coordination mechanisms between the Ministry, donors, and NGOs to, at a minimum, share information on what everyone is doing, promote common strategies and approaches, and ultimately, to come to a common grants mechanism between donors, under the Ministry of Health umbrella.
RO: Beyond the political arena, what your message to partners and donors? To the general public of the United States?
FF: Before any message, first of all we want to say thank you, to express our great appreciation to all those partners—governments, NGOs and businesses—that have been working side-by-side with us since the Transitional Authority was inaugurated last year. We have already made measurable progress and we will make more.
Now to our "message." It is, first of all, to remember the reality: that Afghanistan today has the worst health indicators in the world. We have a horrible situation—a surrealistic situation. Much of today's dilemma is the result of years of war and devastation, both natural and man-made. Now we have to respond to these dire needs for health care.
We know that neither a nation nor the world can be secure if its people, its families, are endangered. Women especially. Our women's lives have been sacrificed by the thousands due to lack of health care. But saving women's lives brings tremendous benefits to society—as mothers, as caregivers, as productive members of the community, as natural peace-makers.
So, I would just want to remind all our partners and donors that their investments in health are investments in peace and prosperity, not just for Afghanistan, but for the region and, beyond it, for the whole world. With their help, we can tackle first things first and move systematically to regain the ground we have lost. Don't leave us alone.