Pre-election insecurity in Afghanistan hampers health service delivery
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《英国医生杂志》
It's three years since the fall of the Taliban; now, with an election looming, Afghanistan's battle is for better health
Mounting insecurity in the runup to the October election is hampering delivery of much needed health services in Afghanistan while severe cash shortages are threatening ambitious government plans to create the country's first modern public health service, say humanitarian and government officials.
Even the humanitarian support that flooded into Afghanistan after the fall of the Taliban in 2001 is waning, most visibly this month when Médecins Sans Frontières (MSF) pulled out of the country after 24 years after the killing of five of its workers in June (12 June, p 1398).
Since then, another non-governmental organisation, Malteser, from Germany, suspended its operations in Afghanistan's restive south east after two of its healthcare workers were ambushed and killed, and the United Nations refugee agency said it was scaling down its operations in the region too.
With less financial support than the Afghan government hoped for from key donors such as the United States and because of spiralling construction costs resulting from escalating violence, the unstable and fragmented country is still struggling to meet its people's most basic health needs, humanitarian and government officials say.
"Ever since the Afghan government was installed at the end of 2001, there have been pledges. Some money came in slowly, some not at all, so that the amounts that arrived and that were implemented into programmes were seen as too little," said Philip Spoerri, head of the Red Cross delegation to Afghanistan, speaking from Kabul.
Others say that even if more funds were available, they could hardly be used effectively given the deteriorating security situation.
"Even if you put more money in, there's not always progress because there's no security," said Claude Mahoudeau, MSF programme manager for Afghanistan, who last visited the country four weeks ago. He added: "I'm sure the Afghan people are fed up with violence, and now they feel they're coming into a new cycle of violence."
A disabled man walks home through the Panshir valley in Afghanistan
Credit: SIPA/REX
For years the health ministry barely maintained the most rudimentary health and immunisation services, with support from the World Health Organization, Unicef, and non-governmental organisations such as MSF and the Red Cross.
Most of those agencies are still there, despite the deteriorating security situation. Mr Mahoudeau said MSF very much regretted leaving but would review the security situation after the October election.
If President Hamid Karzai—who was elected two years ago by a "loya jirga" (a tribal council)—is elected by the Afghan people, as expected, on 9 October, he and his government will once again face one of the world's major health challenges.
Altaf Musani, WHO's regional adviser for Afghanistan, said there were so many different healthcare providers dispersed across the mountainous country that it was vital to ensure quality and a high standard of delivery.
The health challenges are formidable. Afghanistan needs to rebuild the infrastructure of its health service to provide the full range of services but suffers from underinvestment by donors compared with other sectors and a shortage of health professionals, many of whom were killed or fled the country.
Reconstruction will be difficult in areas of insecurity—such as the south east, where Taliban fighters are still active—and where communities are exposed to natural hazards such as earthquakes and floods, said Mr Musani.
"Our chief concern is control of communicable diseases, such as malaria and tuberculosis, and preventing outbreaks like cholera and acute watery diarrhoea (in the outbreak in 2002 there were 70 000 cases), as well as other diseases of concern, like ARI , pertussis, and diphtheria," said Mr Musani, who is based in Cairo, Egypt.
Twenty years of conflict have all but destroyed the country's infrastructure, and Afghanistan's 23 million people have one of the world's lowest health profiles.
The country has one of the highest rates of maternal mortality—160 deaths for every 10 000 births in 2002. One child in four dies before it reaches age 5 years, and life expectancy in 2002 was 43, according to WHO data.
WHO estimates that 20-30% of the Afghan population have "some kind of mental disorder" after years of conflict and displacement and that there are virtually no trained mental health workers or facilities to tackle this.
Researchers recently called on donors and policy makers to tackle the lack of mental health services in Afghanistan (JAMA 2004;292: 575-93).
International agencies, however, point to a few successes: polio vaccinations have halved the number of children paralysed by the disease and 16 million children have been vaccinated against measles.
Some 7.2 million women of childbearing age were vaccinated against tetanus and 850 000 have been immunised so far this year to reduce maternal and infant mortality from this disease, WHO said.
WHO recently helped advise the Afghan health ministry to draft a national health plan to provide nationwide primary health care, known as the basic service package.
This autumn the ministry will start drafting national policy on secondary and tertiary health with help from international health agencies to create two models of hospital: provincial and national.(Fiona Fleck)
Mounting insecurity in the runup to the October election is hampering delivery of much needed health services in Afghanistan while severe cash shortages are threatening ambitious government plans to create the country's first modern public health service, say humanitarian and government officials.
Even the humanitarian support that flooded into Afghanistan after the fall of the Taliban in 2001 is waning, most visibly this month when Médecins Sans Frontières (MSF) pulled out of the country after 24 years after the killing of five of its workers in June (12 June, p 1398).
Since then, another non-governmental organisation, Malteser, from Germany, suspended its operations in Afghanistan's restive south east after two of its healthcare workers were ambushed and killed, and the United Nations refugee agency said it was scaling down its operations in the region too.
With less financial support than the Afghan government hoped for from key donors such as the United States and because of spiralling construction costs resulting from escalating violence, the unstable and fragmented country is still struggling to meet its people's most basic health needs, humanitarian and government officials say.
"Ever since the Afghan government was installed at the end of 2001, there have been pledges. Some money came in slowly, some not at all, so that the amounts that arrived and that were implemented into programmes were seen as too little," said Philip Spoerri, head of the Red Cross delegation to Afghanistan, speaking from Kabul.
Others say that even if more funds were available, they could hardly be used effectively given the deteriorating security situation.
"Even if you put more money in, there's not always progress because there's no security," said Claude Mahoudeau, MSF programme manager for Afghanistan, who last visited the country four weeks ago. He added: "I'm sure the Afghan people are fed up with violence, and now they feel they're coming into a new cycle of violence."
A disabled man walks home through the Panshir valley in Afghanistan
Credit: SIPA/REX
For years the health ministry barely maintained the most rudimentary health and immunisation services, with support from the World Health Organization, Unicef, and non-governmental organisations such as MSF and the Red Cross.
Most of those agencies are still there, despite the deteriorating security situation. Mr Mahoudeau said MSF very much regretted leaving but would review the security situation after the October election.
If President Hamid Karzai—who was elected two years ago by a "loya jirga" (a tribal council)—is elected by the Afghan people, as expected, on 9 October, he and his government will once again face one of the world's major health challenges.
Altaf Musani, WHO's regional adviser for Afghanistan, said there were so many different healthcare providers dispersed across the mountainous country that it was vital to ensure quality and a high standard of delivery.
The health challenges are formidable. Afghanistan needs to rebuild the infrastructure of its health service to provide the full range of services but suffers from underinvestment by donors compared with other sectors and a shortage of health professionals, many of whom were killed or fled the country.
Reconstruction will be difficult in areas of insecurity—such as the south east, where Taliban fighters are still active—and where communities are exposed to natural hazards such as earthquakes and floods, said Mr Musani.
"Our chief concern is control of communicable diseases, such as malaria and tuberculosis, and preventing outbreaks like cholera and acute watery diarrhoea (in the outbreak in 2002 there were 70 000 cases), as well as other diseases of concern, like ARI , pertussis, and diphtheria," said Mr Musani, who is based in Cairo, Egypt.
Twenty years of conflict have all but destroyed the country's infrastructure, and Afghanistan's 23 million people have one of the world's lowest health profiles.
The country has one of the highest rates of maternal mortality—160 deaths for every 10 000 births in 2002. One child in four dies before it reaches age 5 years, and life expectancy in 2002 was 43, according to WHO data.
WHO estimates that 20-30% of the Afghan population have "some kind of mental disorder" after years of conflict and displacement and that there are virtually no trained mental health workers or facilities to tackle this.
Researchers recently called on donors and policy makers to tackle the lack of mental health services in Afghanistan (JAMA 2004;292: 575-93).
International agencies, however, point to a few successes: polio vaccinations have halved the number of children paralysed by the disease and 16 million children have been vaccinated against measles.
Some 7.2 million women of childbearing age were vaccinated against tetanus and 850 000 have been immunised so far this year to reduce maternal and infant mortality from this disease, WHO said.
WHO recently helped advise the Afghan health ministry to draft a national health plan to provide nationwide primary health care, known as the basic service package.
This autumn the ministry will start drafting national policy on secondary and tertiary health with help from international health agencies to create two models of hospital: provincial and national.(Fiona Fleck)