Too good to be true? An assessment of health system progress in Afghanistan, 2002-2012.

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Too good to be true? An assessment of health system progress in Afghanistan, 2002–2012 a

b

Markus Michael , Enrico Pavignani & Peter S. Hill

c

a

Independent Consultant for Public Health and Humanitarian Aid, São Paulo, Brazil b

School of Population Health, The University of Queensland, Maputo, Mozambique c

School of Population Health, The University of Queensland, Brisbane, Australia Published online: 17 Oct 2013.

To cite this article: Markus Michael, Enrico Pavignani & Peter S. Hill (2013) Too good to be true? An assessment of health system progress in Afghanistan, 2002–2012, Medicine, Conflict and Survival, 29:4, 322-345, DOI: 10.1080/13623699.2013.840819 To link to this article: http://dx.doi.org/10.1080/13623699.2013.840819

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Medicine, Conflict and Survival, 2013 Vol. 29, No. 4, 322–345, http://dx.doi.org/10.1080/13623699.2013.840819

Too good to be true? An assessment of health system progress in Afghanistan, 2002–2012 Markus Michaela*, Enrico Pavignanib and Peter S. Hillc a

Independent Consultant for Public Health and Humanitarian Aid, São Paulo, Brazil; School of Population Health, The University of Queensland, Maputo, Mozambique; c School of Population Health, The University of Queensland, Brisbane, Australia


b

(Accepted 31 August 2013) The bold decision was taken in Afghanistan in 2002 to provide donorfunded public health services by means of contracting-out of predefined health care packages. This study seeks to identify the extent to which progress has been made in public health services provision in the context of broader state-building agendas. The article argues that the provision of public health services was also intended to generate a peace dividend and to legitimize the newly established government. The widely portrayed success of the contracting model is backed up by very high official figures for health service coverage. This contrasts with evidence at household level, which suggests limited utilization of public health services, and perceptions that these offer inferior quality, and a preference for private providers. The dissonance between these findings is striking and confirms that public health care cannot remain immune from powerful market forces, nor from contextual determinants outside the health field. Keywords: Afghanistan; health service development; health system analysis; contracting-out; state building

Introduction A public health service has been created out of almost nothing in post-2001 Afghanistan with massive donor support. Recurrent reports of continuous progress in the health field (Bousquet 2005a; Waldman, Strong and Wali 2006; Loevinsohn and Sayed 2008; The Globe 2011; Newbrander, Waldman, and Shepherd-Banigan 2011) contrast with the observed failure to achieve peace (Giustozzi 2009) and the involution of the new state built by modernizers sponsored by foreign powers (Suhrke 2007; Giustozzi 2008). This study raises a series of questions around the progress in public health service provision in this post-conflict context and the capacity to isolate this progress from broader issues of state-building. Are expectations that public health service provision contributes to state-building well founded? And how *

Corresponding author. Email: [email protected]

© 2013 Taylor & Francis

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much, if at all, can a public health service develop and perform better than the deeply flawed state-building process would lead us to expect? This article contributes to a growing debate on the potential benefit of health interventions for state building by shedding light on the particular case of Afghanistan. Gordon (2012) states that: health is advanced as a means of legitimating the evolving state to the people over whom it seeks dominion. Health then becomes a tool with which to foster respect for the state by making it relevant to ordinary people’s lives and establishing a process which constructs a social contract from which stability might derive. Health interventions have therefore become firmly enmeshed in liberal state-building models. In Afghanistan and Iraq health has become not only a part of this wider endeavour but is also widely portrayed as a pillar of the counter insurgency and stabilisation strategies.

Gordon warns, however, that there is very little peer-reviewed evidence of the contribution of public services on government legitimacy and the trade-offs arising from the reduced profile of the state where international donors dominate service delivery – as is the case in Afghanistan – recommending instead that the ‘primary objective of health provision should remain the enhancement of health outcomes’. Eldon, Waddington and Hadi (2008) provide a comprehensive conceptual framework for linking health sector activities and state building, concluding that this linkage is not systematically understood and that more evidence is needed. On the contrary, they warn that pressures for a ‘quick fix’ can lead to by-passing the fragile state, with long-term consequences. Specifically for Afghanistan, Lockhart (2007) noted that ‘contrary to donor pressures to ‘deliver the peace dividend’ rapidly in the form of ‘quick impact projects’ implemented through NGOs, there were clear signs that the citizenry understood, unlike donors, that reconstruction of large infrastructure and public institutions would take years, if not decades’. For more than three decades, Afghanistan has been a country at war. Post-2001, the plan of the foreign intervening forces, in its ultimate form, was to develop and modernize Afghan society, stabilizing it and effectively precluding the possibility of it again harbouring terrorism (Suhrke 2007). Ottaway (2003) pointed out at that time that the international community was proceeding in Afghanistan with the goal of making that country into a democratic secular state without even knowing the desires of the Afghan population, concluding – prophetically – that the model was thus ‘an imposed model, even if it calls for democracy’. It was probably legitimate to refer to the Afghan context as ‘post-conflict’ after the overthrow of the Taliban regime by international military forces in 2001; in the words of a USAID official to the author in 2002, the idea at that time was ‘to have elections and get the hell out of here’. Yet, the International Crisis Group has argued that state building efforts were ‘warped from the start’ (ICG 2007). Large swathes of the country have since been engulfed again in


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an open conflict, or are actually controlled by the insurgency (Giustozzi 2009). An uneasy equilibrium had been achieved by mid-decade in a vicious circle of insecurity, weak rule of law and thriving illegal economy (Riphenburg 2006). Chaudhuri and Farrel (2011) considered it entirely possible by the end of the decade that ‘things will get worse on the strategic side of things’. A decade since their inception, no-one dares qualifying the state building efforts in Afghanistan as a success; quite the contrary, commentators agree to classify them as a failure (Lockhart 2007; Oxfam 2008; Jacob et al. 2009). There was no ‘health system’ to speak of in 2001 (Waldman and Hanif 2002; Pavignani, Modol, and Colombo 2002); what little public healthcare was provided at that time was operated by NGOs in a fragmented way or, in the case of disease-specific programmes, vertically by UN agencies (Bower 2002). Unregulated private healthcare provision dominated the market (Banzet et al. 2007). The focus on public Primary Health Care services in 2002 represented, therefore, a quantum leap. A Basic Package of Health Services (BPHS) was defined to be implemented largely through a process of contracting-out to NGOs (in its second version: MoPH 2005). It was complemented in 2005 by the Essential Package of Hospital Services (EPHS), which allows for a very basic service profile for secondary hospitals (MoPH 2005a), though it lacks the well-defined budget commitment of the BPHS. The main donors for both packages since their commencement have been USAID, the European Union and the World Bank. The rapid scale up of the BPHS was achieved through contracting out of public health services to NGOs. Introducing a purchaser-provider split model to Afghanistan was a major change given the historical tradition of state provision (Bousquet 2005); in the short term, it was considered as the appropriate option for the rapid expansion of services (Loevinsohn and Harding 2005; Newbrander 2007). While contracting-out had been initiated in Cambodia in a limited number of districts, and incrementally increased, it had never been implemented on such a large scale as in Afghanistan. This factor in itself deserves independent review. The advantages, limitations and pitfalls of contracting-out are well described (Vining and Globerman 1999; Palmer and Mills 2005; Palmer et al. 2006). This analysis critically examines the development of the Afghan health sector since 2002, and in particular the contribution of the BPHS and EPHS to the health system as a whole, framing this in terms of the broader state-building agenda for Afghanistan supported by the international donor community. Methods The research employed a case-study approach (Yin 2003), with health service provision in Afghanistan as the focus of research, and is one of six case studies (Afghanistan, Central African Republic, Democratic Republic of Congo,



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Haïti, Palestine and Somalia) undertaken by researchers associated with the University of Queensland between 2010 and 2012. The case studies focused on health service delivery in fragile and conflict affected states (Pavignani et al. 2012). The research primarily used qualitative research methods: documentary analysis, based on a comprehensive literature search, complemented with in-depth interviews and field visits to three sites in Afghanistan, and internally reviewed by colleagues experienced in the Afghan health sector. The literature search used PubMED, Medline and Google Scholar search engines for peer-reviewed literature on health and development in Afghanistan, together with ‘grey’ literature including reports, evaluations and policy documents. Following the elimination of duplicates and irrelevant documents, 124 articles were analysed in an annotated bibliography before the commencement of field work. Between 26 November and 20 December 2010, a total of 44 in-depth interviews were conducted by MM in Kabul city and two provincial capitals: Herat, in the West and Mazar-i-Sharif, in the North, providing access to agencies engaged in contracting out of health services. The interviews used a common thematic question guide developed by the authors, and contemporaneous note taking, with interviews written up on the same day. Purposive sampling of respondents ensured representation of all key stakeholders, including international and national respondents at central and provincial level. Respondents included representatives and project managers of bilateral health donors, senior officials of UN health agencies, the International Committee of the Red Cross, the Afghan Red Crescent Society and international and Afghan NGOs, as well as national professionals working for international academic institutions. Within the central MoPH, 13 senior advisors, departmental heads and programme directors were interviewed, and one provincial senior staff member (see Table 1). Interviewees were responsible, among others, for health policy, health finance, human resources and training at a central level, and for the BPHS and EPHS, Maternal and Child Health, Polio, HIV/AIDS, Tuberculosis, pharmaceuticals, prison health services and academic research. Under the Table 1.

Respondents by category and location.

Respondents Bilateral donor UN agency International Committee of the Red Cross INGO Academic institution National NGO Afghan Red Crescent Society MoPH Total

Central

Provincial

Total

4 2 2

0 3 1

4 5 3

5 3 1 0 13 30

3 0 4 2 1 14

8 3 5 2 14 44


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informed consent required for ethics approval from the Research Ethics Committee of the University of Queensland, assurance of confidentiality was extended to all informants, and the limited identification of sources reflects this protection of respondents. The timeframe and security issues precluded direct consultation of users and beneficiaries. Our research was provided access to these perspectives through near-contemporary studies conducted by colleagues at village level (ACBAR 2011, Cockcroft et al. 2011). The analysis was also informed by extensive professional experience in Afghanistan of MM, who has cumulatively worked for more than four years in the country since 1995 (Michael et al. 1999; Michael and Roth 2012) and EP who conducted an assessment in 2002 (Pavignani, Modol, and Colombo 2002). PSH has supervised research in Afghanistan in 2011–2012 (Mansoor, Hill, and Barss 2012). While the yield of documents on Afghanistan and its healthcare arena was very rich, the raw data available for research is problematic. A serious shortcoming is the unreliability of all indicators prior to 2001, which makes comparison with these baselines questionable. The reliability of the available data has improved only in part over the years, due to persisting constraints not amenable to correction. A recent controversy about the results of the Afghanistan Mortality Survey 2010 (Hill 2012) fully proves the point. Quantitative comparisons over time have, therefore, to be considered with the utmost caution, and sometimes altogether discarded as invalid. In the light of the challenges posed by such a complex subject and environment, this article attempts to describe patterns identified by qualitative research, supplemented where possible by reliable quantitative data, and drawing on accounts from those currently working in the Afghan health sector, matching these to the authors’ personal experience, and triangulating findings through peer review and the feedback of a substantial network of colleagues currently, or previously working in Afghanistan. Findings and discussion Policy actors: donors and the Ministry of Public Health The MoPH is widely considered one of Afghanistan’s best functioning Ministries – a fact underlined by continued donor confidence. From the start, donors have aimed at strengthening the MoPH’s stewardship role and have contracted external technical assistance in order to consolidate this role. The MoPH in turn recognized early the importance of recruiting, training and retaining talented Afghan professionals and keeping them motivated (Belay 2010). It proudly asserted in 2010 that it had managed, since 2003, more than 500 million dollars of donor funds in a very transparent and accountable manner (MoPH 2010). Yet, though nominally in charge, the resources that MoPH officials have managed are primarily those received from foreign agencies and



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governments (Jones et al. 2006): the MoPH remains almost entirely donor-dependent to date. While strengthening stewardship and governance, direct donor support to vertical programmes like HIV/AIDS prevention and Drug Demand Reduction has simultaneously lead to significant fragmentation of the MoPH. The central institution also has little control over the provincial offices (‘the MoPH – this is Kabul only’, a provincial NGO respondent scoffed). These, in turn, have varying levels of engagement: they are not included directly in the funding chain of the service packages, but may influence outcomes indirectly, often ceding to local pressures and interests that are not always health-related. One phenomenon repeatedly reported, for instance, is the concentration of health facilities in the village of origin of the provincial health director – rather than in locations that would lead to greater utilisation. Members of the provincial health offices do participate, however, in joint supervision visits of health facilities, the intensity varying according to the province, and the expected local outcomes of supervision: ‘they go to the nearest health facility, not further than 5 km away’ (Provincial NGO respondent). While the Policy and Planning Directorate of the MoPH has succeeded in formulating sub-sectoral policies and strategies, the performance of the MoPH in devising an over-arching health policy and implementing concrete action plans has been less convincing. Respondents have described the overall planning process as incremental, with ad hoc additions and modifications, lacking a comprehensive and sustainable vision. Insufficient continuity at high policy level has also been observed to be problematic, owing to a rapid turnover of key MoPH officials in general, and with each change of Minister. Since the initial agreement on the packages to be financed, there has been little donor coordination. Meetings between the three key health donors are as a rule informal and irregular: ‘the EC comes and tries to play the game, USAID comes, but doesn’t play the game, and the World Bank doesn’t show up’ (International agency respondent). Despite their effective control of the policy agenda and implementation through their dominance in financing, the donors’ role as purse-holders contrasts with their low visibility, which limits the potential to hold them accountable. Limited capacity within the MoPH and the high level of donor dependence makes donor coordination difficult. Key MoPH staff members, benefitting directly from very significant salary supplementation from donors, can be considered as de facto donor employees. The NGOs who were awarded initial contracts in the BPHS were for the most part international NGOs, or their local satellites, already present in Afghanistan at that time. Despite their role as main service providers, NGOs have had limited inclusion in policy-making (Bousquet 2005), and the marginal contribution of relevant UN agencies to defining health policy in 2002 led to reported perceptions of sidelining by the donors (Bower 2002; Sondorp 2004).


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The BPHS: formulation and early promise The initial definition of a BPHS allowed for four levels of facility, from Health Posts over two levels of Health Centres to District Hospitals. Funding allowed for a purchaser–provider split, with each of the three main donors (USAID, the European Union and the World Bank) funding the BPHS for roughly a third of Afghanistan’s 34 provinces. Contracting-out awarded NGOs contracts for whole provinces, or in some cases a cluster of districts. Coverage with health facilities grew – admittedly, from very low numbers – exponentially (Waldman, Strong, and Wali 2006), confirmed by indicators such as user rates (Belay 2010) and the uptake of specific services such as Antenatal Care (Bousquet 2005). By the end of 2010, the public health network consisted of close to 2000 health facilities, approximately a threefold increase since 2001. The BPHS has also expanded its service profile, introducing mental health and nutrition in 2005, and health care for nomads and prisoners in 2010. The 2002 decision to contract-out health service provision to NGOs was agreed between the Ministry of Public Health (MoPH) and the main health donors, following a joint donor mission, with the World Bank the strongest advocate for its adoption (Sondorp 2004). The MoPH recognized the need for a national health policy that promised comprehensive coverage, met through the persuasive arguments for contracting-out, and the commitments of powerful donor agencies. This same core of donors (and a handful of others) has in turn funded NGOs through a special unit within the MoPH to provide the commonly agreed service profile. The strategy, however, was essentially solution driven, with a focus on early implementation meaning that comprehensive analysis of the healthcare arena, or extensive discussion of policy alternatives was not pursued. The implications of such a policy choice were not initially fully appraised, though several studies carried out after its official adoption, to prepare the ground for its implementation, or to assess its progress, have pointed to the challenges implicit in this ambitious initiative (Newbrander et al. 2003; Waldmann and Hanif 2002; Strong, Wali, and Sondorp 2005). Donor efforts at institutional support have initially been concentrated on the MoPH unit managing the BPHS contracts (Sondorp 2004; Schemionek et al. 2009). In order to ensure the success of the BPHS, dedicated arrangements allowed this unit to channel donor funds directly, largely bypassing other departments and the bureaucratic constraints of civil administration (Bousquet 2005). Given this degree of autonomy, the contract-managing unit is still considered by some respondents as a sort of ‘Ministry within the Ministry’, and characterized by more than one respondent as a ‘project implementation unit’. In 2012, the quarterly reports at the central MoPH on BPHS progress continued to be delivered separately on the basis of donor support, with three presentations by three different speakers and under three different programme titles. But the commitment to strengthen the Ministry as a whole has grown throughout the decade, with other MoPH departments receiving



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direct separate funding and technical assistance, despite the difficulties of institutional building in a fragile context fragmented by targeted donor investment (Schemionek et al. 2009). The annual costing of delivering the BPHS, set at USD 4.55 per beneficiary (Newbrander et al. 2003), was seen as vastly unrealistic (Strong, Wali, and Sondorp 2005), when compared with the USD 12 estimate proposed by the World Bank (1993) and the much more substantial figure of USD 34, set in 2001 by the Commission on Macroeconomics and Health (2001). The yearly allocation to BPHS NGOs rose by the end of 2010 from USD 4.55 to close to USD 5 per capita, though given the currency depreciation since 2003, the actual allocation has fallen. This very low operating cost has induced competing NGOs to underbid each other to the point that their programme proposals no longer match their own written budgets: a number of NGOs have been found operating with budgets of roughly USD 3.5. A NGO representative argued that it would be impossible to provide the services specified in a project proposal with the financial resources requested for the same project. Despite the many concerns voiced, none of those interviewed unequivocally regretted the decision to introduce the purchaser–provider split, given the constraints of the post-2001 context. Regarding its implementation, however, respondents mentioned an uneven playing field for NGOs, with under-cutting by unscrupulous competitors and preference for new and Afghan NGOs. According to Waldman, Strong, and Wali 2006, ‘three-quarters of the Afghan NGOs that competed for contracts have been formed since 2001, specifically to deliver the BPHS’. While the indigenization of service provision is a desirable development outcome, initial contracts were expected to be awarded to established international NGOs, as in Cambodia, and the transfer of responsibilities may have caught some local NGOs unprepared. With contractors changing over successive contract periods, there were both economic and structural costs incurred by replacing providers who had already established supportive local networks. Frequent mention of corruption hinted at the possibility of rent seeking through the contracting process, and transparency in the contracting process was judged by some to be limited. One NGO which lost a provincial contract to a competitor complained that the donor ‘gave every time different reasons for changing the implementer’ (Provincial NGO respondent). A frequently voiced suspicion was that contracts were awarded on the basis of the quality of the proposal document and size of its budget, rather than on NGO performance – a practice justified by donors as fostering competition rather than giving an undue advantage to the incumbent implementer. The BPHS: issues of implementation Public health service provision has made significant progress over the short decade (Belay 2010), although from a very low base level (Oxfam 2008); as one international agency respondent ventured: ‘any strategy adopted at that


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time was bound to succeed, considering that there was nothing’. External funding to health supported such progress by expanding fivefold between 2001 and 2008/2009, attaining the sizeable level of about USD 11 per year per capita (Belay 2010). There was a consensus among respondents, however, that momentum was lost somewhere around 2007, owing to a variety of interrelated factors: insecurity, decreased quality of implementing NGOs, corruption and donor fatigue. The ‘least-cost’ approach apparent in the contracting process was seen as directly contributing to a loss of quality of care, with one international NGO respondent questioning the focus of a contract which ‘includes everything in the budget but health’. Implementing NGO respondents complained that the use of official demographic figures based on an extrapolation of a partial 1997 census results in budgets that are significantly underestimated when compared with the significantly higher current populations encountered in activities such as immunization campaigns. Respondents from provincial centres pointed to numerous rent-seeking opportunities, especially among NGOs purpose created as BPHS implementers. NGOs have been suspected of importing the cheapest drug available and charging for a better version (‘China produces paracetamol for two, ten or 25 Afghanis’; provincial NGO respondent), of retaining salaries while bank deposits accumulate interest or of pocketing the salaries of staff allegedly working in health centres that are actually closed owing to insecurity. One provincial respondent reported that staff members on the payroll of a health facility in an insecure rural area were frequently encountered in town. Rent seeking by health facilities staff themselves is common in the form of unofficial payments or bribes (Cockcroft et al. 2011). Hiring health professionals – especially women – for rural areas has proven difficult and in many cases, impossible. Health worker shortage has been a key theme throughout the decade (Bower 2002; Belay 2010), caused mainly by strong distributional imbalances (MoPH/EC 2008; MoPH 2010): urban vs. rural, doctors vs. nurses and other professionals, and men vs. women – with growth in health professionals compounding these imbalances. New urban private medical schools are producing medical graduates beyond the absorptive capacity of health services (Fritsche 2005); Acerra et al. (2009) reports 11,000 currently enrolled in training as doctors, and Wikipedia (2013) currently lists 17 medical schools in Afghanistan, compared to six in 2002. Despite considerable progress made, the production and quality of health professionals has suffered from relative neglect (MoPH 2010). Market forces pull health professionals away from the public service or out of the country altogether (Taksdal 2005), which results in a high and damaging staff turnover. The absolute numbers of female health professionals have increased; their very low presence in rural areas, however, still constitutes a major obstacle for access to health care for women and girls (Mansoor, Hill, and Barss 2012). One implementing NGO reported losing 40% of its female BPHS staff in one province over the course of one year in 2011. Another common phenomenon



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is that doctors working in a health centre, instead of fulfilling their official working hours, squeeze all the consultations into a very short morning presence, with negative consequences on the length and quality of consultations. A number of respondents questioned the reliability of health data, pointing to persistent contradictions between official figures and data locally produced through household surveys. In part, the paucity of data results in the recycling of poor quality – but available – data. Short-term technical advisors, without the time to critically evaluate the evidence, repeat these dubious statistics in their reports, reinforcing their authority: ‘foreign consultants, without ever leaving Kabul, produce reports from fake data produced for them’ (International NGO respondent). Persistently high and growing figures for immunization coverage contrast with localized measles outbreaks reported, for instance, from Kandahar and Helmand provinces in 2010 (International agency informant). The bias introduced by insecurity into surveys and routine data collection also limits data reliability. The 2006 Afghanistan Health Survey noted: ‘Twentyeight clusters [of 425 sampled clusters] were not completed due to security reasons’. Reports commonly provide an initial disclaimer, stating that insecure areas were excluded, but the implications of this are not further explored, with the accessible sample used as if it represented the national situation. Monitoring and evaluation suffers especially in insecure areas, in quality and quantity, owing to the requirement that it be undertaken by ‘out-of-town’ professionals: a provincial NGO respondent conceded, for instance, that ‘they know we only come on bazaar days’. In addition to routine supervision and the use of the Health Management Information System, the ‘Balanced Scorecard’ (BSC) was developed as a monitoring and evaluation instrument by contracted research institutions (Edward et al. 2011). The tool consists of a list of common indicators, according to which health facility performance is evaluated in a yearly exercise funded by the World Bank. The BSC also used to replace health facilities in insecure areas in its sampling (which, according to an international NGO respondent, ‘would all be in the red’) with facilities in secure areas. Moreover, the BSC is felt by many respondents to be too reductionist in its design, too much ‘a part of the system’ (funded by the World Bank) and too flawed in its implementation (Bousquet 2005; Maury 2005; Schemionek et al. 2009; Belay 2010) to serve as a reliable independent monitoring instrument. The contracting and reporting process itself represents a considerable burden on implementing NGOs whose senior staff spend more time working on donor proposals and reporting than on supervising their operations; both international and local respondents would recommend donors preoccupy themselves more with the quality of care rather than being ‘obsessed with finances and procedure’. The implementation of the ambitious packages was marked by very limited step-by-step plans for ‘how to get from here to there’, as suggested by Bower (2002). The inevitable implementation gaps encountered in local implementation are inconsistent with the public accounts of progress, but the gap between


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this official narrative and the reality on the ground has become increasingly recognizable, as attested by successive surveys. The Afghanistan Health Survey 2006 (MoPH 2006), the Demographic and Health Survey 2010 (DHS 2010), the Afghanistan Private Sector Health Survey 2009 (USAID 2009) and the Afghanistan Mortality Survey 2010 (Afghan Public Health Institute et al. 2011), all show poor although improving key health indicators. The very high official figures for contracting coverage (often mistaken for health service coverage), reaching beyond 80% (Newbrander et al. 2007; Loevinsohn and Sayed 2008; IRA/ANDS 2008) are contested in practice, on the grounds of loose definitions of ‘coverage’, significant under-reporting of incomplete implementation or outright health facility closures caused by insecurity (Jones et al. 2006; Simmonds and Ferozuddin 2008), lack of resources or corruption (ACBAR 2011) and insufficient consideration of the actual use of public health services. The debates confirm Palmer and Mills’ (2005) contention that contracting-out primary care services is of low measurability, but high contestability. Other authors simply question the validity of the term ‘coverage’ by bringing quality of care and health outcomes into the equation: ‘most of the Afghan population does not have access to the basic services that could make a large difference to their health’ (WHO 2006), or ‘anecdotal evidence suggests that the quality of services provided is poor, with long waiting times, absence of laboratory services, shortage of drugs, and even disrespect for patients’ (Sabri et al. 2007). These earlier findings were confirmed by a survey conducted in Kabul province in 2008, with a mean of 42.5% of households qualifying public health services as bad/very bad (Cockcroft et al. 2011). A series of focus group discussions at community level conducted by another researcher in 2011 still revealed lack of access to and availability of health services, and their perceived inferior quality as major issues. There were regular issues with staff not attending the clinic or lack of equipment and drugs; in some areas, clinics had no medicine for months. The title of the media report, based on a quote, was eloquent: ‘Health and Education in Afghanistan: An Empty Gift’ (ACBAR 2011). A 2006 household health survey showed that less than half of patients sought care at a public health facility, and revealed low service coverage, such as births attended by a skilled health worker (19%), and fully-immunized children (27%) (MoPH 2006). The 2010 Afghanistan Mortality Survey showed an improved but still low figure for skilled birth attendance: two-thirds of deliveries took place at home (DHS 2010). Also, disease-specific national programmes such as the National Tuberculosis Control Programme have not fulfilled expectations: bone tuberculosis was found to be the second most frequent cause of spinal cord injuries in Afghanistan (Michael and Roth 2012). Even where there is evidence to the contrary, claims of success are maintained. The example from the extensive Community Health Worker (CHW) programme as part of the BPHS serves as a significant illustration. According to the BPHS, one Health Post, staffed by a female and a male CHW, is to be


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established for every 1000–1500 inhabitants. By the end of 2010, there were around 22,000 CHWs registered in Afghanistan. MoPH representations of the CHW reflect this contradiction; the CHW,


is often the preferred provider for first level of care and for emergency services, though results from the household survey indicate that a majority of women report having no knowledge of a CHW working in the community and in only a small percentage of cases did women report that care was sought from a CHW for an illness of injury experienced by someone within the household in the previous 30 days. (MoPH 2007)

In our research, MoPH respondents asked about the actual activities of the CHWs, mostly listed the activities CHW were supposed to carry out, and not what they actually knew about these. A limited number of NGO respondents admitted that owing to insecurity, supervision of Health Posts had been discontinued, or that ‘out of 100 Health Posts, only 20 were effective’, or simply that ‘we don’t know what they do’. Health financing The disconnection between reported contracting coverage and service utilization may also be explained by under-estimated delivery costs: under-funded NGOs expected to provide health care to a whole contracted-out area managed to serve only a modest portion of its population. With hindsight, the under-estimation of the true cost of delivering the BPHS looks indicative of the optimism then permeating donor perceptions. Although public spending on health has gradually risen to USD 10.92 per capita by the end of 2010, it remains low as percentage of GDP, given as just under 2.7% (Belay 2010). The general unwieldy government bureaucracy leads to very significant under-spending of the MoPH’s own modest funds. External assistance – which has levelled off in recent years – represents 85% of public spending (Belay 2010). Donor funds are increasingly on-budget and channelled through the Ministry of Finance, although still earmarked and tracked. Without an alternative funding source other than external assistance in view, public health service provision is liable to remain aid-dependent for years to come. Batley and McLoughlin (2010) warn that excessive reliance on aid calls into question the contribution of government stewardship and public service delivery to state-building – a significant justification of the initial donor investment. In any case, if the Western political and military disengagement from Afghanistan is followed by a consequent contraction of aid flows, it will impact negatively on the expanded yet fragile public healthcare provision system. Despite an international consultation convened in 2007 (Carlson et al. 2007) drawing attention to the overall inadequacy of public expenditure on health, in 2008, Parliament legislated the populist decision of ‘free public

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health care for all’, without providing an alternative for healthcare financing other than external funds. Despite this offer of ‘free care’, household out-ofpocket expenditure remains by far the largest source of health financing in Afghanistan, dwarfing all other funding sources, and capable of forcing poor households into catastrophic expenditure (MoPH 2006).


Private healthcare providers: the persisting alternative In a 2008 survey devoted to private health care, health spending was confirmed as the dominant component of household expenditure (USAID 2009). Yet, available evidence suggests that patients continue to seek primary care from private rather than public providers (USAID 2009; Cockcroft et al. 2011). Private health services (provided by an eclectic mix of skilled, semi-skilled and many unskilled operators) still dominate the market in Afghanistan (Belay 2010). This is the case more in urban than rural areas – where public services are also hardest hit by the increasing insecurity, with the range of available services compromised or unavailable. Private provision in Afghanistan remains unregulated (USAID 2009); as one respondent formulated it: ‘corruption and regulation are clear problems: the first is rampant and the second absent’. There is also a vast overlap of public and private provision of care; most public health professionals engage in private care after or during working hours (Banzet et al. 2007). Household interviews conducted in 2008 in five provinces revealed a dominance of private healthcare providers, who accounted for 75% of total encounters (USAID 2009). Private healthcare provision is characterized by poly-pharmacy (Bousquet 2005), with the unnecessary prescription of more medications than are clinically indicated and care that is poorly informed and at times is clearly dangerous. Private pharmaceutical channels also provide the majority of essential medicines in Afghanistan, but government regulation is not adequate to ensure the quality of drugs imported and sold: Afghanistan has been called a ‘pharmaceutical dustbin’ of substandard, counterfeit, adulterated and diverted medicines (Harper and Shahab 2008). While donors and NGOs have undertaken separate initiatives toward the end of the decade to strengthen the pharmaceutical subsector, these are not an adequate alternative to comprehensive reform, however, with a focus on building the regulatory power of the MoPH. More recently, the private sector’s services profile has expanded from physicians in solo practice to polyclinics, diagnostic centres and hospitals; the focus, however, concentrates always on curative care only, with preventive care relegated to MoPH and collaborating agencies. For those who can afford it, hospital care is sought abroad (MoPH 2010): in Pakistan, India or Dubai, on a sliding scale according to purchasing power. Hospitals in Pakistan and India are reported by MoPH informants to employ Dari and Pashto speaking receptionists to cater for Afghan clients. A study on spinal cord injuries (SCI) conducted in April 2012 (Michael and Roth 2012) found that nine out of 16



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patients with SCI from the north-west of Afghanistan – the region farthest away from Pakistan – had sought hospital care in Pakistan and even India. Considering the huge market represented by healthcare provision, the limits of existing governance capacity and the high level of corruption in the country, the establishment of an effective regulatory regime to contain this trend faces major challenges. Yet, the future outlook of the healthcare arena will depend more on the way privatization is managed than on any other policy decision. Conversely, every aspect of public healthcare provision will be affected by private forces. The determinants of the privatization drive are clear: poor access to public services has established alternative sources of care; inadequate public funding has compromised quality of services in the scale up of coverage and encouraged user charges. The overproduction of physicians has boosted supply (USAID 2009) and regulatory weaknesses have facilitated the growth of private practice, with private pharmaceutical suppliers dominating the market, all inducing demand. This thriving sector of the healthcare arena has been invisible to information systems, biasing health policy formulation. In the case of each of these drivers, governance functions (or their absence) have played significant roles. Governance and accountability: present and future challenges Yet, governance within the public sector is also troubled. The roles of donors and the MoPH are interdependent and blurred in Afghanistan; the consequences of this on the service delivery compact between users, interposed NGO providers and the state are an obscuring of the governance structures that a purchaser–provider split assumes. With the exception of three provinces where the BPHS is ‘contracted in’ to the MoPH and roughly a dozen provincial hospitals where the MoPH implements the EPHS, the MoPH is not itself a service provider. But, while it has regulatory responsibility for the BPHS, it is itself heavily dependent for funding on the same donors who have sponsored the basic packages. It exercises only limited regulatory activity or supervisory presence in the provinces, and provincial health officials do not have a strong sense of local ownership of health services, given their marginalization from funding and contracting decisions. For those we interviewed, for instance, it was not clear where accountability for health service delivery lies. An international researcher reported the frustrations of a village council member from Ghor province: ‘we have taken our issues to the government. They listen and make promises but there is no action. We need a responsible and accountable government’. But in health, government accountability for services, because of the complex governance structures, is not local. Arguably, the NGOs, to whom the ‘government’ has contracted health services, should be locally accountable, and anecdotal evidence suggests that each NGO awarded a contract for a territory is perceived as accountable for the suc-


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cesses, but especially the failures, of healthcare provision (Jacob et al. 2009). NGOs, however, have little decision-making discretion within their tight budget constraints. Their desire for continuance of their funding makes them more accountable in their perspective to the donors than to the MoPH, and much less to the population or the state. Yet the donors, ultimately responsible for the funding, have an ambiguous role within the purchaser function – which nominally has been handed to the MoPH. At the local level, they do not maintain a conspicuous presence in terms of oversight of services and are not accessible to health service users. To date, donors have largely determined which activities of the MoPH to fund, though currently the European Union and the World Bank are providing a future pool fund (the System Enhancement for Health Action Transition (SEHAT) fund) for the 22 of Afghanistan’s 34 provinces that they currently support. The SEHAT will be made available to the MoPH at its discretion within the agreed policy framework for five years from 2013, and is seen as a precursor to a possible Sector-Wide Approach (SWAp) to health. This is intended to give greater financial ownership to the MoPH and offset the unintended consequences of selective funding within the MoPH, with departments that do not benefit from direct donor support unable to attract the necessary skills, and idle owing to lack of operational funds. While funding and technical assistance may accomplish the establishment of an organization, the transformation into sustainable institutions is dependent on domestic political processes, which take time and can only be marginally affected by donors (Ottaway 2002). Owing to the overwhelming constraints of the fragile environment, its own weak governance and piecemeal donor interventions, the MoPH has not quite become a unified organization (much less, an institution), but rather a hybrid structure in which donor and national elements are entwined. The progress towards a SWAp may serve as a transition, with donors committed to a shared policy framework under local leadership and the management of both domestic and donor resources, but with mutual structures of accountability. Whilst Newbrander et al. (2011) argue that ‘Improvements in health services and systems help to strengthen civil society and to restore legitimacy to governments’, other analysts are more cautious. Eldon, Waddington, and Hadi (2008) conclude that there is little, if any, clear evidence on the relationship between health system strengthening, citizen and state expectations and the social compact between the state and society. The introduction and focus on Primary Health Care in 2002 is rightly considered a significant step forwards. But, we would argue that the focus on the BPHS, and the drive to national coverage, has replaced more comprehensive health policy-making with a focus on one particular dimension. In the years that have followed, preoccupation with the rolling out of the BPHS has side-lined other key issues such as financial management, hospital care, human resource development and the pharmaceutical sub-sector.



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With the state considered too weak to provide public health services (Palmer et al. 2006), and plenty of NGOs already delivering services on the ground, the choice of contracting appears appropriate. Managing, regulating, monitoring and evaluating the contracting process, however, requires a strong administrative capacity. If it is not endowed in the state, it has to be brought in from outside. In Afghanistan, the donors have ‘solved’ this conundrum through keeping control over the process, retaining direct financial control over BPHS and EPHS budgets through their respective contracting teams within the MoPH, and through supplementing salaries of key MoPH officials, effectively maintaining decision-makers in the MoPH as their proxies. On balance, the outcome of the effort to build a public health system in Afghanistan is neither an unmitigated success nor an abject failure. Among the key successes is the focus on Primary Health Care per se and access (admittedly at some cost) to some public health services for some of the population. The relative failure to reach many rural and remote areas (and especially their female populations) can largely be attributed to the resurgence of the armed conflict. The low level of funding of both BPHS and EPHS, combined with widespread absenteeism and other implementation shortcomings, has contributed to creating a perception of low-quality public health services and, where possible, provoked migration to and expansion of private provision. After initial growth and expansion until roughly 2007, a relative downturn in the evolution of public health services was observed, which cannot be attributed to a single cause (other than the resurgence of the armed conflict). It has to be understood as a warning, however, that with all the goodwill and efforts, public health services can stay ahead of the rest of a country in troubles for a while, and thanks to robust external support; development cannot be sustained without the expectation of stability and economic growth (Hill, Mansoor, and Claudio 2010). Conclusion The moderate progress of the public health services in Afghanistan, and their uncertain future, cannot be understood without strong reference to the context. Given the global political imperatives that drove the defeat of the Taliban, the urgency surrounding the building of a ‘modern state’ is not surprising. In light of Afghanistan’s long history of successful resistance to being governed by a central administration (Giustozzi 2008), it may seem unrealistic. The assumption that conflict simply disrupts the normal functioning of any state, which can then be readily restored with judicious donor investment, has framed misconceived interventions (Duffield 1996). The transition from relief to rehabilitation to development (Newbrander 2007) has not happened as foreseen; state building in the shape of a militarily installed liberal democracy has failed. Afghanistan proves the point that certain chronically dysfunctional states are not temporary aberrations ‘in transition’ (Chauvet, Collier, and Hoeffler 2007), but are here to stay, with development experience in other countries under


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stress offering little encouragement as to the effectiveness of the state-building process (DFID 2005; Dollar and Levin 2006; Feeny and McGillivray 2009; Cammack et al. 2006). The refractoriness of these societies to being governed by formal state administrations is deeply entrenched, and shaped by their geography, history, culture and, crucially, political economy. Progress within the health sector needs to be understood in this context. Development assistance in Afghanistan has been ‘transformational’, strategically contributing to building the state through stabilization and economic growth (Barder 2009), with the provision of public health services in Afghanistan legitimizing the newly established and democratic government, contributing to stability and peace (Newbrander 2007; Zoellick 2008; Goodhand and Sedra 2010). But, this in turn has made the success of the BPHS an intrinsic part of this transformational agenda (Mojumdar 2010). The BPHS has become a visible symbol of the state moving towards regeneration, with an inflated ‘optimal presentation’ necessary in preserving support in the donor community, as much as meeting domestic expectations. In this rhetoric, the geographical coverage of health services – a provider perspective – has been persistently privileged over their quality – the consumer perspective (Belay 2010). The neglect of quality now seriously endangers trust in the BPHS and EPHS and, in a perverse twist, threatens the perceived legitimacy of the government (ACBAR 2011). Yet, health status and health service provision are co-determined by a number of interdependent factors that mostly lie outside the health sector. Progress within health is inevitably constrained (or facilitated) by the social and economic progress of the country as a whole. In dysfunctional states, aid may have a palliative – as opposed to an ameliorative – role (Chauvet, Collier, and Hoeffler 2007). Effective aid is dependent on building a structure of good policies and institutions (Collier and Dollar 2002). Public health sector (re)construction can only progress as much as the (fragile) state context allows. The rollout of the BPHS has been a courageous undertaking; the rapid geographic extension of public health infrastructure over previously uncovered territory impressive. Yet, the focus on demonstrable progress, the unrealistic costing and the questionable outcomes of the tendering process have deflected attention from critical questions: what is the quality of the offered services? How has the provision of BPHS and EPHS changed the patterns of health-seeking behaviour over the past decade? While the BPHS is largely accessible throughout the country, it competes unfavourably with the private sector in terms of utilization. Private healthcare provision is developing in step with economic growth, filling every perceived market gap, under the distracted sight of a state unable to regulate it. Meanwhile, in a context that retains many of the characteristics of acute humanitarian interventions, public healthcare provision, with it matrix of civil and military providers, is characterized by fragmentation, verticalization, donor dominance and aid dependence.



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The creation of the MoPH out of almost nothing is an impressive feat, but the almost absolute dependence on donor funding, creates an unsustainable ménage-à-trois between donors, MoPH and NGOs. This points to the tensions implicit in seeking to legitimize the state through the external funding of public healthcare provision. While donors pay lip service to local ownership, the MoPH has limited control of donor funding that is inadequate for the ambitious coverage projected, and does not yet exercise the regulatory and supervisory reach that would ensure that NGOs perform effectively in health service delivery. As Eldon, Waddington and Hadi (2008) point out, the decision to transfer health service delivery functions to NGOs risks undermining public perceptions of the state, particularly where they are struggling to maintain legitimacy. And while health care makes a limited, though respected contribution to popular perceptions of a functioning state, it is only one component of the overall state structure. Security, rule of law, human rights, representation and taxes, all contribute much more to the citizens’ perception of the state than healthcare provision (Hill, Mansoor, and Claudio 2010). While donor agencies wait for the tortuous, slow and painful emergence of viable indigenous state structures, they must pay attention to health needs and demand, and the pluralist and unregulated nature of those health service responses that emerge to fill the persisting gaps. This will require very different engagements with local stakeholders, and varied strategies that invest in existing and diverse local capacities, working incrementally with communities emerging from a traumatic past into an uncertain future. Could supporting the healthcare arena in Afghanistan be approached in a different way? The differences would be marked in terms of extended timeframes, a deep sense of the local context, development of local institutions, incremental but informed progress. First of all, the broader context should be thoroughly appraised and continuously monitored. The trajectory in a relapseprone environment such as Afghanistan will experience reversals and failures. Rather than a single prescriptive national approach, a variety of strategies within a broadly inclusive policy envelope, adapted locally to address the great internal diversity, may build more diffused, decentralized capacity, rather than concentrating investment in a centralized state administration. Strategies should build on ground-level experiences and grow incrementally, by adding innovations intended to fill gaps, as they are recognized, in an open-ended evolutionary process. Second, monitoring and evaluating developments in the field should embrace the whole healthcare landscape, rather than narrow programmatic activities. In this way, emergent patterns are likely to be identified earlier, and inform future programmes better. Third, the local context is paramount: highly structured interventions are unlikely to be sustained in unstable, informal settings: flexible and adaptable approaches are needed. Fourth, the responsiveness of the health service, and its accountability to the population it serves, are more important than conformity to service provision models. Fifth, in an environment where state governance structures are poorly

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developed, there is value in the exploration and development of those structures that are present, and potentially beneficial to health service delivery. Establishing non-profit pharmaceutical supply agencies, building on community governance, or collaborating with local civil society institutions, are examples of such an approach. Finally, stakeholders beyond the state must be given adequate voice in policy discussions. Their knowledge of health services and influence over them may vastly surpass what is endowed in public institutions.


Acknowledgements The research was undertaken as part of the project ‘Providing Health Care in Severely Disrupted Environments: A Multi-country Study’, largely funded through the Danish Government Ministry of Foreign Affairs. The authors thank Maurizio Murru for contributions from his own fieldwork and to the research as a whole, and Althea-Maria Rivas for details from her field research. Gyuri Fritsche, Egbert Sondorp, Lindsay Morgan and Ilkhom Gafurov made helpful comments on a draft of an earlier report.

Notes on contributors Markus Michael is an independent consultant for public health in countries affected by war. Following clinical work as a doctor in Latin American countries, he managed humanitarian health programmes for the ICRC in countries in armed conflict and at headquarters. His main interest in consulting since 2001 – which takes place in numerous war-affected countries of all continents – lies in the analysis of resilience and vulnerability of health systems under stress, and the search for appropriate humanitarian aid in the health sector. Enrico Pavignani is a public health physician who has worked in developing countries for more than 30 years in a variety of roles: district doctor, trainer, planner and policy analyst. He has studied many distressed African and Asian healthcare arenas, concentrating his interests on the impact of crisis on health services, on their responses and on measures supportive of their recovery. Associate Professor Peter Hill is a public health physician and academic at the Australian Centre for International and Tropical Health, the University of Queensland. His research and teaching interests are in global health policy and governance and health systems reform in developing countries. He has worked extensively in Aboriginal Australia, Africa, South-East Asia and the Pacific, with collaborations with major European institutes of tropical medicine.

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Research accomplishments that are too good to be true.

Research accomplishments that are too good to be true: comment.

Vitamin A supplements--too good not to be true.

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Lung ultrasound in the intensive care unit: an idea that may be too good to be true.

Too good to be true: when overwhelming evidence fails to convince.

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Response to Katz et al.: lung ultrasound in the intensive care unit: an idea that may be too good to be true.

stress questionnaire: too good to be true?

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Implications of "Too Good to Be True" for Replication, Theoretical Claims, and Experimental Design: An Example Using Prominent Studies of Racial Bias.

Perioperative supplemental oxygen to reduce surgical site infection: too easy to be true.

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Haiti making good progress in health but challenges remain.

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Exercise may be detrimental in hypertension: too much of a good thing!

Progress toward the assessment of health status.

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