The First Step in Rebuilding Afghanistan's Health Care System

As Mohammad Afzal approached the health facility, located on a long, dirt road in a southwestern province of Afghanistan, he saw the darkness inside. Like so many he had visited before, the clinic does not have electricity or running water. He passes the large group of women sitting outside with children in their arms, trying to shield themselves from the hot summer sun. The flies swarm around them, and the air holds a pungent odor, a mixture of urine, feces, and heat-warmed bodies.

The women, holding their children protectively in their arms, have already waited hours in the heat and have yet to see a nurse. There are no doctors in the clinic. These women traveled long distances-by foot, horse, or mule, because their children are sick. They have not eaten today. Many did not eat yesterday. The mothers' tired and worn faces match those of their children-too young to fully understand why their stomachs hurt. A sound of cries from inside the clinic startles Mohammad. He goes inside to hear the nurse explain that they have run out of medicine; the children cannot be helped today. They will have to come back to the clinic another day or find some way to buy medicine from a private pharmacy.

Mohammad Afzal is one of the nearly 170 Afghan surveyors trained by MSH to assess the status of health services in provinces throughout Afghanistan. These are the stories he and the others listened to every day. The wide-scale survey they conducted of more than 1,000 health facilities is the first assessment of health services carried out in this war-ravaged country in over a decade.

The Afghanistan government and international donors see the survey as a necessary first step in rebuilding the health system. The results of the survey will provide them with a comprehensive view of health services throughout the country. The Ministry of Health will release the results later this year and use them to set priorities, conduct planning workshops, and implement health services in areas with the greatest needs.

Information is Crucial

After more than 23 years of war and conflict, much of the health services infrastructure throughout Afghanistan has been completely destroyed. According to preliminary results from the national survey, about one-third of facilities are in need of repair, half the facilities do not have safe water, and more than 30 percent have no electricity.

Further, when the last national health resources survey was conducted by MSH in the early 1990s, surveyors discovered that 30 percent of health facilities listed as open and operating were actually nonexistent, closed, or nonfunctioning. Meanwhile, they found a number of facilities that were not listed but were open and providing services to the local community. This information allowed donors and organizations to redirect investments to functioning facilities and to underserved areas, saving scarce resources for health priorities.

While quantitative information on the current health situation in Afghanistan is unavailable or out of date, the health status of the population is among the worst in the world. One in 4 children dies before the age of five. One in 15 women die in childbirth, and most deliveries occur at home, without supervision by trained medical professionals.

Given the magnitude of the problems and the desire of both the Afghan government and international donors to act quickly to improve the condition of women and children throughout the country, the Ministry of Health requested that MSH take the technical lead in conducting a national survey of health resources.

Because information about health resources in Afghanistan has become so out of date and in anticipation of a large-scale reconstruction of the country, the Ministry of Health and MSH decided not to sample health facilities. Instead, they decided to conduct a comprehensive inventory of all known health facilities-while also identifying and surveying new facilities found in the course of the field visits.

Conducting the Survey

Afghan surveyors are trained to collect data. Photo by MSH staff.

The Ministry of Health, MSH and its Japanese partner, HANDS, worked with a variety of international agencies and organizations to develop plans for the survey and to identify surveyors. Through these collaborations, the Ministry recruited 167 local staff (all Afghan male nationals) as surveyors.

Financial support for the survey came from multiple donors, namely, the US Agency for International Development and the European Commission, as well as UNFPA and the Japan International Cooperation Agency. Their collective support has helped to ensure that planning will identify priorities, which is particularly important in an environment like Afghanistan where resources are scarce.

MSH and HANDS first administered a three-week, intensive training course for the surveyors to demonstrate how to use data collection questionnaires, global positioning systems, and cameras to record information about the health facilities. Field visits during training allowed participants to practice key skills before beginning the actual survey.

On July 11, armed with their new skills and equipment, the surveyors were sent out in teams throughout Afghanistan to map the location of and record information about existing health facilities and workers and other potential providers of health services, such as private pharmacies.

Many of the surveyors were pleased with their new jobs, simply because it meant a steady stream of work for a few months. However, they also recognized the important roles they were playing in the development of Afghanistan's health system. As one surveyor, Mr. Rafiullah, expressed it, "We will face many difficulties, but we must be patient and find our way. A good result of this survey will help a lot in Afghanistan. We are taking the first step for health facilities in Afghanistan. This survey will help us to organize our aid. People need good medicine. They need health care, education, and opportunities."

The survey covered all provinces and 326 districts in Afghanistan and captured information about the location of facilities, services provided, qualifications of personnel, needs for rehabilitation or renovation, availability of essential drugs, and availability of health workers at the village level. Surveyors visited health facilities, community-based health providers, and pharmacies nationwide to obtain an accurate and comprehensive database of available health resources.

Survey teams consisted of two people. Each team was assigned a target area consisting of several districts within a province and given a list of facilities to visit within that area. The survey teams were assigned to visit more than 800 facilities, extracted from a database maintained by the World Health Organization. Surveyors were also encouraged to search their target area for facilities not included in their lists.

Like the survey of more than a decade ago, the current survey found that almost 16 percent of the 829 listed facilities were inactive. Moreover, surveyors identified an additional 207 functioning facilities that had not appeared on their lists. In other words, of the 1,038 total facilities surveyed, 905 are presently active in Afghanistan.

Lessons and Experiences

Afghan doctor examining baby. Photo by MSH staff.By the end of August, the 85 teams of surveyors returned to Kabul. To ensure the survey's quality, monitors were sent out to revisit 10 percent of health facilities and to verify that information recorded by the surveyors was accurate.

While some of the surveyors' journeys were difficult at times, the majority of them obtained all the information they set out collect, even from areas considered to be extremely dangerous. How was this possible?

Critical to the success of the national survey was the Ministry of Health's strong support and leadership, as well as the use of local surveyors. The Ministry informed officials within the provinces and districts and delineated the expectations and goals of the national survey. In addition, the Ministry engaged the support of the local media, mainly radio, to inform communities throughout Afghanistan about the purpose of the survey and the importance of the surveyors' work. Finally, most the surveyors were drawn from, or were familiar with most of, the provinces or districts to which they were assigned.

Next Steps

During September, 23 data entry staff and 7 translators, supported by MSH and HANDS staff and survey supervisors, worked two shifts a day to rapidly compile the results. After completion of the data entry, initial survey results were presented in October to the Ministry of Health.

More detailed results will be presented to the Cabinet in early November, and by mid-month, with financial support from the European Commission and the US Agency for International Development, a national dissemination workshop will take place, involving the Ministry, donors, UN agencies, nongovernmental organizations, and provincial representatives. Provincial dissemination and planning workshops in 18 provinces will follow the national workshop.

While final results from the survey are not yet available, one thing is clear: Afghanistan's Ministry of Health is committed to rebuilding the health system and using the survey results to focus donor priorities and build provincial and international support for improving health.

Will donors respond with the sustained support needed to ensure the success of these efforts and significantly improve the health of women, children, and families throughout Afghanistan? The answer remains unclear.