Bolstering the Gains in Afghan Health Care

By Praful C. Patel, vice president of the World Bank’s South Asia region (THE WASHINGTON POST, 04/08/07):

A few weeks ago, The Post published a heartbreaking story of Afghanistan’s health-care system breaking down as the insurgency seems to advance. Medical workers have disappeared (one was beheaded), doctors are seeking safer places to work and clinics are running out of medicine because deliveries have become too dangerous. The added cruelty of this news is that Afghanistan’s health system had just begun to turn a corner.

Today, 40,000 more Afghan babies a year are living beyond their first birthday than survived to that age in 2002. Recent household surveys and health facility assessments carried out by experts from Johns Hopkins University indicate how rapid progress in the health sector has been. The infant mortality rate has declined 24 percent since the fall of the Taliban in December 2001. The number of mothers who have someone skilled to help them give birth has increased from fewer than 50,000 in 2002 to more than 190,000 in 2006.

The expansion of health services has meant that every year, 15,000 more cases of tuberculosis are properly diagnosed and treated than were under the Taliban. Routine polio immunization rates have doubled.

Overall, the researchers found, residents of rural communities have dramatically greater access to health services, and the quality of those services has improved markedly.

I have seen some of this turnaround. I recently paid a surprise visit to a simple health center in a mountainous part of Samangan province late one afternoon. Happily, I was the one surprised: At 5 p.m., the staff was still present and cheerfully looking after patients. Like all the other health centers my colleagues and I have visited recently in Badakshan, Baghlan, Sar-e Pol, Balkh and Parwan, this one was clean and well stocked, and it had a trained female health worker available to look after female patients and their children. This worker was one of more than 1,000 newly trained community midwives.

After she finished counseling a young mother, I asked the health worker a few questions. She was typically shy but was also clearly — and rightfully — proud of her work and skills. This woman came from a distant village where she was one of few women who could read or write. She had received 18 months of training from a nongovernmental organization using a curriculum developed by Afghanistan’s Ministry of Public Health.

The progress in Afghanistan has been impressive and the improvements in citizens’ lives tangible. But it is important to keep in mind where the country was just five years ago: in the ashes of war and brutal oppression. There is still so much to do.

The international community can help sustain the achievements made so far. The first and most urgent task is to help improve security. As the Post article showed, the Taliban has been cynically targeting health workers and health facilities with devastating effect.

In Helmand province in the south, 11 of 440 health workers have been killed in the past year, and nearly half of all health facilities there have been closed. This becomes perfect propaganda for the Taliban, which tells villagers that the government cannot provide them with services. Without dramatically improved security, it is hard to see how health services can improve further. Indeed, we are seeing the negative effects as health workers are burdened, too, by trauma casualties among civilians caught in the crossfire.

The international community must also keep providing financial support.

While providing health care in Afghanistan is not that expensive in absolute terms, the country’s mountainous terrain presents an additional challenge. There is also little infrastructure to support distribution. Perhaps as important as how much money international donors provide is the way that that money is channeled. The government has proved in health and in other sectors that it can properly manage the funds it receives from donors. Yes, there is corruption in Afghanistan, but some sectors, such as health services, are managing to largely avoid this trap. Keeping donations to Afghanistan outside government budget flows doesn’t prevent corruption, and, indeed, may reinforce bad practices.

Ironically, it is an old military adage that seems to offer the best advice for going forward: Make sure you don’t reinforce failure, and make very sure you reinforce success. When a breakthrough is occurring, additional support is critical to victory. The health sector in Afghanistan requires urgent reinforcement.