Traditional health care sector, mainly medical care centres and physicians at its core, has been concerned with individuals’ disease diagnosis and treatment, while public health efforts have been focused on populations’ health promotion and disease prevention. In Afghanistan, the focus of the health care system is on providing Basic Package of Health Services (BPHS) and Essential Package of Hospital Services (EPHS). The service packages are developed nationally and provided throughout the country similarly by government and non-governmental organizations (MoPH, 2009). BPHS is the primary care provided for the population. In this policy paper, I am looking into the health care system of Afghanistan – its structure, its delivery and its funding. I will first examine BPHS through the lens of primary health care as it is defined by the Alma Ata Declaration. Then I will consider integrating public health efforts at the primary health care level and in the health care system in Afghanistan. Finally, I will propose some policy recommendations.
Primary health care
The concept of primary health care is best described in the Alma Ata declaration of 1978.
‘Primary health care is essential health care based on practical scientifically sound and socially acceptable methods and technology made universally accessible to individuals and families in the community through their full participation and at a cost that the community and country can afford to maintain at every stage of their development in the spirit of self-reliance and self-determination. It forms an integral part of both the country’s health system, of which it is a central function and main focus and of the overall social and economic development of the community. It is the first level of contact of individuals, the family and community with the national health system bringing health care as close as possible to where people live and work and constitutes the first element of a continuing health care process.’ (World Health Organization, 1978)
The definition of primary health care goes beyond primary medical care and includes community participation, individual and family involvement, and the focus of overall social and economic development. Currently, the primary health care in Afghanistan – the Basic Package of Health Services – deals with a number of predetermined general issues identified in the national level. It entirely ignores the needs of the local community.
C.E.A. Winslow in 1923 defined Public Health as the science and art of preventing disease, prolonging life, and promoting physical health and efficiency through organized community efforts for the sanitation of the environment, the control of community infections, the education of the individual in principles of personal hygiene, the organization of medical and nursing services for the early diagnosis and preventive treatment disease, and the development of the social machinery which will ensure to every individual in the community a standard of living adequate for the maintenance of health.
In short public health is ‘the science and art of preventing disease, prolonging life and promoting health through the organised efforts of society’ (Acheson, 1998). Public health services are delivered to whole populations, or sub-groupings of the whole population, at national, regional and local levels. They include health protection and health promotion.
Afghan health care system
Afghanistan is one of the poorest developing countries with over 29 million populations (USDS, 2010). Life expectancy at birth in this South Asian country is 47 years for men and 45 years for women, slightly more than half of life expectancy in Canada (WHO, 2007). Major health concerns are maternal and child mortality followed by communicable diseases such as tuberculosis and malaria and non-communicable disease such as mental health (MoPH, 2009; WHO, 2009). Human Immunodeficiency Virus (HIV) is also emerging as a serious health problem due to increasing number of drug abusers (WHO, 2009). Other epidemics such as cholera, congo-crimea hemorrhagic fever, measles, meningitis and pertussis are also frequent (WHO, 2009). Moreover, there is a high level of acute and chronic malnutrition (WHO, 2009). With such extensive health problems, the country has 2 physicians and 5 midwives/nurses for each 10,000 people (WHO, 2009) compared to 19 physicians and 101 nurses/midwives per 10,000 people in Canada (WHO, 2007).
The health care system of Afghanistan was rebuilt from scratch after the fall of the Taliban in 2001. Since, the health services were mainly provided by non-governmental organizations, the country has adopted a performance-based contracting health system (MoPH, 2009). The national health program developed by the government is a part of the Afghan National Development Strategy (MoPH, 2009). The Afghan National Development Strategy is a five-year plan for Afghanistan to reach the Millennium Development Goals (MDG) of World Health Organization (MoPH, 2009). The structure of the health system is organized by the Afghan National Development program and the services are provided by non-governmental organizations, also known as contracting partners.
Funding for the health care system comes from international organizations. The three main international donors are US Agency for International Development (USAID), World Bank, and European Commission (ANDS, 2008). Each has taken responsibility of specific number of the 34 provinces of Afghanistan: USAID funds 13 provinces, World Bank 11, and European Commission the remaining 10 provinces (USAID, 2010). The donors along with the health ministry contract out non-governmental organizations for providing health services in rural areas of Afghanistan.
Afghan National Development Strategy (2008) defines Afghanistan‘s health structure as traditional. The entire system is categorized in the following structure based on its referral and supervision system.
Health Posts à Sub-Health Centres à Basic Health Centres àComprehensive Health Centres à CHC+ à District Hospitals à Provincial Hospitals à Regional Hospitals à National Hospitals.
The services provided in this structure are divided in two categories; Basic Package of Health Services (BPHS) and Essential Package of Hospital Services (EPHS). BPHS is the service provided by primary structures such as HPs, Health Sub-centers, BHCs, and CHCs. The basic package of health services (BPHS) in Afghanistan consists of the following components, (1) maternal and newborn health, (2) child health and immunization, (3) public nutrition, (4) communicable disease, (5) mental health, (6) disability and supply of essential drugs. The package is developed nationally ignoring the needs of in the community level.
There are three major issues missing in the public health policy. First, maternal and child health, communicable disease, and mental health are the top national priorities of the government, but the needs of the population differs dramatically in the community level. There is a need for involvement of community in decision making. Second, the Ministry of Public Health is all about primary care and hospital improvements. Besides BPHS and EPHS, there is no national public health initiative or programs. Finally, there is a need for involvement of other sectors such as education, labour and social affairs, public works, and others.
In both the concept of primary health care as defined in the Alma Ata Declaration and the concept of public health, community participation is a common ground. In the Afghan context, involvement of the community in deciding what services should be provided in the primary care packing is a must. Currently, BPHS is a package of services decided by the ministry of health and international organizations at the national level. Had the communities in demographically different parts of Afghanistan were involved in deciding what services to be provided to them, there would have been different focuses in different parts of country. For example, the socio-economically developed north has different priorities than the war-ravaged south. The highly mountainous cold-weathered northeast and central Afghanistan has different health priorities than the flat and hot-weathered south. I suggest that all structure such as Health Posts, Sub-Health Centers, Basic Health Centers, and Comprehensive Health Centers, which are considered as the first point of contact of the population with the health care system, should include the concept of community. They should be renamed as Community Health Posts, Community Sub-health centers, Basic Community Health Centers, and Comprehensive Community Health Centers. This will pave the way for involvement of the community in the primary care, and, once the community involved in health care, it integrates the concept of public health in the primary health care.
The second element which is missing in the public health services of Afghanistan is involvement of other sectors in promoting health and preventing disease. The one very important sector having strong historical ties with public health is education. I recommend school-based public health programs in the Afghan context for two reasons. First, 42% of the Afghan’s population is between 0-14 years and the media age of the entire population is 18.2 years old (Index Mundi, 2011). Second, it will be the first step towards involvement of other sectors in health. Programs such as school-based immunization, child development, teenage consultation, personal hygiene, and so on can strengthen the sectorial ties between public health and public education. This can be a step towards the concept of ‘healthy policy’.
Direct involvement of other sectors in health, as education, is difficult, but possible through policy development. I also recommend a policy towards ‘smoke-free’ government departments and promotion of ‘safety culture’ in all government and non-government organizations. There has not been any national step towards smoke cessation and promotion of safety culture.
To sum it up, Afghanistan has one of the world’s lowest health status. To achieve the millennium development goal in regards to health, the country has to focus more on promoting health, prolonging life, and preventing disease rather than treatment of disease. To do so, there is a dire need for involvement of the community, all government organizations, and other stakeholders in health promotion and disease prevention. School-based public health intervention, smoke-free organizational policy, and promotion of safety-culture could be the start of a public health approach to health care system.
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