Afghanistan : Health

Decades of conflict have left the Afghan health care system in disarray. Shortage of medical equipment, trained staff and proper facilities coupled with unreliable power supplies further compound the problem. To ensure health care services are available to everyone, the Government of Afghanistan and its NGO partners have adopted and are implementing the Basic Package of Health Services (BPHS).

A number of factors set BRAC apart from other national and international NGOs providing health services in Afghanistan. Firstly, BRAC brings with it four decades of experience in innovating and refining rural healthcare delivery systems in Bangladesh. We are able to apply the learnings to help Afghanistan realise the potential of basic health care for all.

BRAC also has extended experience and expertise in developing healthcare capacity at the local level. We have already established an extended network of community platforms that can be leveraged for the benefit of the health programme. Afghan health providers appreciate BRAC’s commitment to improving local health care by training and encouraging front-line health professionals.

BRAC’s roots in Bangladesh (also a developing country in South Asia, with a largely Muslim population) helps us understand and be sensitive to the cultural and socio-economic environment in Afghanistan, adding to our effectiveness. Our partnership management style focuses on a belief in people and a willingness to observe and learn from others. This includes maintaining excellent relationships with the communities in which we work.

In addition, we employ professional managers and financial experts who are knowledgeable and technically competent committed to support our healthcare providers in the field. Our low cost structure allows BRAC to be competitive and to provide more health services for each dollar invested.

Programme description

BRAC’s health programme in Afghanistan aims to:

1. Address the immediate health needs of people in rural areas

2. Partner with the Ministry of Public Health to improve quality of life in rural communities

3. Achieve sustainability by building capacity of local BRAC health programme staff

4. Improve community-level preventative medical care

To understand the health care system in Afghanistan, it is necessary to understand the Basic Package of Health Services (BPHS), which defines free public health care in the country.

Basic Package of Health Services

The Basic Package of Health Services (BPHS) is the foundation of the Afghan health system and sets forth the minimum level of health services for all Afghan citizens. It is revised periodically and the 2005 revision is currently in force. As of 2005, 77% of the population of Afghanistan had access to BPHS services.

BPHS specifies the following health facilities:

Health post: This is the Community Health Worker (CHW) operating out of his or her home providing services to 100-150 households. Health Posts have two CHW’s (one female and one male)

Sub-Health Centre: Staffed by one nurse and one Community Midwife providing basic health services for 3,000-6,000 population in the most remote and inaccessible areas

Basic Health Centre (BHC): This is a small fixed facility offering complex outpatient care. BHCs service 10,000-15,000 people, depending on population density, and supervise the Community Health Workers within its coverage area. The minimum staff at BHCs are: a medical doctor or nurse, a Community Midwife and two vaccinators

Comprehensive Health Centre (CHC): The CHC covers an area of 15,000-30,000 people and offers a wider range of services than the BHC. CHC facilities have:

• limited space for inpatient care
• a laboratory
• a staff which includes both male and female doctors, male and female nurses, midwives and laboratory and pharmacy technicians.

 District Hospital (DH): DHs provide all services under the BPHS, including the more complicated cases. Each DH covers a population of 100,000–300,000 people.

BRAC Innovation: Community Health Promoters

BRAC was the first development organisation in Afghanistan to widely use female Community Health Promoters (CHPs) for whom literacy was not mandatory. Lessons learned from BRAC’s experience contributed to the adoption of female CHW’s in Ministry of Public Health policies.

Our Community Health Promoters (65% female) are generally selected from the communities they serve. Each CHP is responsible for delivering basic health services to 100-150 households containing 1,000 ton 1,500 inhabitants. They visit 5-10 homes a day for 15-30 minutes each. CHP’s perform the following services during their house-to-house visits:

• Health and nutrition education
• Treatment of common ailments
• Non-clinical family planning method distribution
• Identification of suspected TB patients
• Implementation of DOTS (Directly Observed Treatment Short-course) for TB
• Distribution of oral rehydration supplies and iodised salt
• Mobilisation of children for immunisations (Expanded Programme on Immunisation or EPI)
• Education about health and hygiene
• Distribution of Acute Respiratory Infection (ARI) and anti-diarrhoeal medicine
• Referral of complicated diseases to medical facilities
• Distribution of personal hygiene products, e.g. toothpaste, sanitary napkins, etc.

BRAC CHPs receive two levels of training. Their initial 8-week long training teaches them how to perform standardised CHP services and also about basic preventive and curative diseases. CHPs also receive monthly refreshers training at fixed facilities near their home.

The CHPs are volunteers who receive incentives for various services, such as attending monthly review meetings (USD 2), reporting a suspected TB case (USD 1) and completing a DOTS treatment for TB (USD 3). They also distribute heath care products such as oral rehydration solution (ORS) and delivery kits, which they receive free and then sell at a 25% mark-up on wholesale costs.

2009 Health Projects

Carried out with BRAC’s involvement

• Community-based TB Control in Rural Areas
• Private Sector Study
• Community Based Health Programme (CBHP)
• Mobile Health Teams
• In-Service Training Project
• Integrated Behavioural Change Comm. Strategy
• Community Mid-Wifery Education
• Nursing Training
• Special Immunisation Programme
• Child Survival Demonstration Project
• Global Fund Round 8 TB
• Global Fund Round 8 Malaria