Undermining Afghan health care

By Leonard S. Rubenstein and William Newbrander
Sunday, November 29, 2009

Amid the news about U.S. failures in Afghanistan stands a clear success: a vast expansion of primary health-care services, including a major increase in the number of female health workers to provide prenatal care, attend births and treat female patients. By supporting the capacity of the Afghanistan Ministry of Public Health to develop and implement these services, the United States has contributed to a dramatic reduction in deaths of Afghan infants and young children. Yet the approach that fueled this success is in jeopardy of being subordinated to the objective of employing health development resources to support military operations. Such a shift has no proven linkage to enhancing stability in the short term and undermines policies that can contribute to the emergence of a legitimate state.

Afghan life expectancy is only 47 years for men and 45 years for women. More women die in childbirth in Afghanistan than in any country but Sierra Leone. After the U.S.-led intervention in 2001, the U.S. Agency for International Development, the World Bank and the European Union collaborated with the Afghan Ministry of Public Health to extend basic health services to help reduce premature, preventable deaths, especially among women and children. This initiative has been supplemented by special programs focusing on reducing death in childbirth, training health workers and tuberculosis control.

Despite uncertain security conditions, severe shortages of health workers and almost no health infrastructure, progress is clear. As has been noted in journal articles and reports from the Afghan health ministry, donors and academic evaluators, the number of health facilities has doubled and the number of trained midwives quadrupled. The share of health facilities with at least one female health worker has climbed to 83 percent. The number of children dying in infancy or before age 5 has declined nearly 25 percent, which translates into nearly 100,000 fewer infants and children dying this year, compared with 2002.

These initiatives have strengthened the foundations of a state that can serve its people. Rather than providing or contracting for services directly, USAID, the World Bank and the European Commission have strengthened the capacity of the Ministry of Public Health to develop and implement health policies, oversee programs, manage resources, engage communities and control the delivery of services. In contrast to the corruption obvious elsewhere, the health ministry has shown a level of transparency and accountability that allows U.S. funds to flow directly to the government for the provision of basic health services.

Saving lives through effective prevention and primary care services remains daunting in such a poor and chaotic country. Much remains to be done to extend health services nationwide, especially in regions where fighting inhibits access. But foreign assistance in this field has helped save thousands of lives and has built sustainable government capacity.

Unfortunately, such work for Afghanistan's future is at risk. In an effort to win over populations in Taliban-controlled areas, the Obama administration is considering reducing overall funding for USAID health programs and concentrating development resources to support military operations. This means moving funds to certain geographic areas and emphasizing immediate results. Yet there is no evidence that expensive "quick impact" health projects that are not integrated into a larger strategy, or that do not actively engage locals, either contribute to security or wean populations from the enemy.

Quick-impact projects, such as clinic construction or the provision of new medical equipment, are rarely sustainable and seldom based on the community engagement needed for long-term effects. These simplistic and immediate interventions have been known to backfire. One military health analyst has criticized "drive-by" health interventions as "Band-Aid" operations that raise -- and then crush -- local expectations and ultimately lead to greater dissatisfaction and distrust. Moreover, as resources are diverted from the Afghan-led effort to build a system of effective and responsive primary care services, the emergence of a legitimate state will be compromised.

If the Obama administration is serious about supporting the emergence of a legitimate Afghan state and meeting the needs of people who have suffered for decades, it should not confuse health policy with military strategy. The United States should maintain its commitment to proven approaches in Afghan health care and support the Ministry of Public Health's plans for expanding primary care and hospital services. Washington can continue to fund critical health services in areas of conflict. Afghan health officials, working with U.S. assistance, can develop and expand health services in volatile areas as safety increases. This approach would not divert U.S. health-development activities from the long-term goals of promoting good health and effective governance for Afghans.

Leonard S. Rubenstein, a visiting scholar with the Center for Public Health and Human Rights at the Johns Hopkins Bloomberg School of Public Health, researched health reconstruction in areas of conflict as a senior fellow at the U.S. Institute of Peace last year. William Newbrander, a senior technical officer with Management Sciences for Health, is a senior adviser to the Ministry of Public Health of Afghanistan. His work with the Afghan ministry is funded by USAID through the Basic Support for Institutionalizing Child Survival (BASICS) project.

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