Structural inequity in the Afghan primary health care

The Basic Package of Health Services (BPHS) is designed to provide services to the population in greatest need – the rural population and women and children, but the structure of the package and the way health facilities are distributed in the rural areas feed inequity in health services against the poorest of the poor. In this blog, I cast light on urban/rural disparity, the assumption behind the equity approach in the BPHS, and the inequity in the structure of the BPHS.

Initially, the disparity in health services take origin from the urban/rural divide, with the structure of the health facilities designed in a way that those in larger towns, populated areas, receive more, better services than those in remote and isolated areas. Modern medical services have been widely available in urban Afghanistan since the second half of the 20th century. Hospitals were established in Afghanistan as early as 1920s; Kabul medical school was inaugurated in 1932, followed by a nursing school in 1936. In 1962, there were 56 hospitals in Afghanistan mainly in cities and town centers. But the rural population has often been unfairly left out of the public services. In 1973, only 10 per cent of the rural population had access to basic health services. A number of Western health advisers worked with the Ministry of Public Health (MoPH) between 1973 to 1979 in order to provide basic services to the rural population, but their progress were slow until 1979, and reversed in 1980s with the establishment of communist government in Afghanistan.

In 2003, The Basic Package of Health Services was planned to take health services to the rural and under-served populations. The package aimed to reduce inequity in health services across the country, but the BPHS remained unsuccessful due to the level of medical services provided at the rural health facilities, and many other structural factors beyond the health system. Significant determinants of health that lay beyond the health system in rural areas of Afghanistan are shortage of drinking water, ubiquitous lack of proper latrines, absence of electricity, unpaved, bumpy and blocked roads, and lack of adequate secondary schools and higher education institutes. Most importantly, these structural inequities are accepted realities of living in rural areas as if the notion of ‘rural’ carries with it a naturalized reality of being underprivileged. No one dares question it.

The disparity in health services does not end with urban/rural division. Within the rural context, the only BPHS structure that takes into account a horizontal equity approach is the Health Post, or the services provided by the Community Health Workers (CHWs). Horizontal equity is defined as equal treatment of the equals. The assumption of the BPHS also is that all rural Afghan populations have a number of similar major health problems: i.e. poor maternal and child health, a number of prevalent and communicable diseases, lack of water and sanitation, and low health awareness. Based on that assumption, policymakers have decided to provide similar services, by the CHWs, to the entire rural populations. BPHS and Hospital Sector

But the structures above the HPs are different for different population. There are four major health facilities above a HP.

  • Health sub-center (HSC)
  • Basic health center (BHC)
  • Comprehensive health center (CHC)
  • District hospital (DH)

These health facilities are hierarchal in terms of their equipment and the services they provide. A health sub-center has a male nurse and a community midwife, and treats diarrhoea and pneumonia, and provides immunization, antenatal care, family planning, and TB case detection and referral, and follow up. All of the services at a sub-center are also provided by CHWs at a HP.

A BHC has a nurse, a community midwife and two vaccinators providing further services such as postpartum care, normal delivery and newborn care, routine immunizations; and integrated management of childhood illnesses, and treatment of malaria and tuberculosis. This center does not provide obstetric care or any other emergency care.

A CHC has a male and a female physician, which is 0.33 – 0.66 physicians per 10,000 people, providing all the services at the BHC plus handling certain complications of delivery, grave cases of childhood illness, treatment of complicated cases of malaria, and outpatient care for mental health patients. Even the CHC does not provide emergency obstetric care.

The most equipped health facility at the rural level is the district hospital, which has a number of doctors, including female obstetricians/gynecologists; a surgeon, an anesthetist, a pediatrician, a psychiatrist, or psychosocial counsellors/supervisors; midwives; laboratory and X-ray technicians; a pharmacist; a dentist and dental technician; and one to two physiotherapists. The district hospital conducts major surgery under general anesthesia, X-rays, comprehensive emergency obstetric care, and male and female sterilizations. It offers comprehensive outpatient and inpatient care for mental health patients and rehabilitation for persons requiring physiotherapy with referral for specialized treatment.

Each of these health facilities has a number of HPs, and provide referral services to the population served by those HPs.

According to this model of services, the population covered by a district hospital are highly privileged over the ones covered by a health sub-center or a basic health center. They are even better served than those at a comprehensive health center. To clarify, an emergency patient in a village that is covered by a district hospital is directly referred to the hospital, and receives the care she needs. On the contrary, an emergency patient referred to a health sub-center will most likely not get the service she needs, and be referred to a basic or comprehensive health center. If she survives the second referral to a BHC or CHC, she won’t be receiving any care in those facilities either, and only will be referred to a district hospital. Only if she survives the third referral, she might get the care she needs at the district hospital. The design clearly indicates that the structure of the facilities favour those living near the towns or district centers.

The poorest of the poor, the underprivileged living in remote communities and isolated villages remain underserved. I acknowledge that the way rural communities are make provision of equitable health services very difficult, but acknowledging the problem can be the first step to tackle it. The BPHS needs a significant revision and change in the structure that leads to removal of many layers of referral by having a basic health post at the village level linked to a comprehensive, equipped health facility/hospital that provides all necessary services including obstetric and emergency care. An appropriate referral mechanism including accessible transportation will be enough to serve the rural population equitably.

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