NEWS

Insecurity and lack of funds hamper progress on Afghan health service

Khabir Ahmad

Karachi

Ambitious Afghan Government plans to provide basic health-care services to 25 million Afghan people who have one of the lowest health standards in the world are being hampered by a lack of funds and mounting insecurity, government and humanitarian officials said.

Abdullah Sherzai, Deputy Minister of Public Health, told the Bulletin that his ministry was still waiting for almost half the funds needed for this year's budget alone.

Donors, like USAID and The World Bank, have approved the Afghan Government plan. But some donors are not providing enough funds for this, preferring more visible projects with more immediate results, such as building a big hospital in Kabul and other cities, officials say.

"Out of a total US$ 200 million we budgeted for the provision of the Basic Package of Health Services (BPHS) this year, only 50–60% of the money has been disbursed," Mr Sherzai said, speaking from Kabul in August.

The Basic Package initiative, developed by the Afghan Government in cooperation with nongovernmental organizations (NGOs), and United Nations agencies including WHO, aims to provide a standardized set of basic health services at primary level to improve the health status of Afghans.

Maternal mortality is alarmingly high, with about 1700 women dying for every 100 000 live births because of complications that could easily be prevented. The situation is worse in remote areas.

The country has one of the highest infant mortality rates in the world — with 165 deaths per 1000 live births. One in four children die before their fifth birthday. Life expectancy at birth is only 46 years.

Most Afghans, particularly those in rural areas, do not have access to health care because more than two decades of war have destroyed or damaged the majority of health facilities and educational institutions, and many health-care workers have been displaced or killed.

Dr Khalid Shibib of WHO's Emergency and Humanitarian Action Department said that although access to health care in Afghanistan has been improving slowly, it is not very different to many other underdeveloped countries.

A serious problem is a lack of mental health resources and a shortage of professional mental health care workers. A team of researchers warned in August that the prevalence of mental disorders in Afghanistan was alarming and required immediate attention by donors and policy-makers (JAMA 2004;292:575-93).

"With decades of war, the people of Afghanistan have gone through uniquely traumatic experiences that have affected their mental health," said Dr Barbara Lopes Cardozo, a psychiatrist at the Centers for Disease Control and Prevention in Atlanta.

"In our study of the mental health, social functioning, and disability in postwar Afghanistan, we found significantly high levels of depression, anxiety and post-traumatic stress disorder," Dr Cardozo said.

"Sixty-eight percent of people showed signs of depression, 72% had symptoms of anxiety, and 42% had symptoms of post-traumatic stress. As a comparison, levels of depression in the United States are lower at 8–10% and 1–2% for post-traumatic stress," Dr Cardozo said.

Increasing attacks on humanitarian workers — 32 aid workers have been killed since March 2003 — have put much of the country off-limits to international health-care workers and jeopardize much-needed investment.

"For quite some time we have been unable to get to people in rural areas mainly because of the security issue", said Jessica Barry from the International Committee of the Red Cross (ICRC) which provides vital trauma and surgical services in Afghanistan.

"Because of insecurity in rural areas, our work remains limited to large urban centers", Ms Barry said.

In July, a leading humanitarian organization, Médecins Sans Frontières pulled out of Afghanistan after five of its workers were killed in Badghis province.

But despite the lack of security and shortage of funds, major progress has been made in many areas including policy-making and measles vaccinations, and towards polio eradication.

"The number of polio cases in the country has been reduced to only three this year because of relentless efforts made by WHO, the Afghan Government and others," said Ahmed Shadoul, a medical officer at WHO Afghanistan.

A good acute flaccid paralysis surveillance system to check for polio is in place all over Afghanistan with more than 450 sentinel sites and about 4400 reporting points.

In August, WHO launched an initiative to reduce in less than two years the incidence of leishmaniasis, a disabling disease transmitted by sand fly which often leads to facial disfigurement. Kabul has 67 500 cases, more than anywhere else in the world.

The project is in cooperation with the Massoud Foundation, an Afghan nongovernmental organization, and Dutch non-profit group HealthNet International and was funded by a donation from the Belgian Government.