Building health systems in fragile states: the instructive example of Afghanistan

In The Lancet Global Health, Nadia Akseer and colleagues1Akseer N Salehi A Hossain SM et al.Achieving maternal and child health gains in Afghanistan: a Countdown to 2015 country case study.Lancet Glob Health. 2016; 4: e395-e413Summary Full Text Full Text PDF PubMed Scopus (66) Google Scholar document the fairly positive maternal and child health outcomes achieved in Afghanistan over the course of a little over a decade. The publication of the Article is timely because the global health community is grappling with the lessons learned from the Millennium Development Goal period and also with the outcomes of several Ebola-related reviews.2National Academy of MedicineThe neglected dimension of global security: a framework for countering infectious disease crises. National Academy of Medicine, Washington, DC2016: 1-144Google Scholar A message common to many of these reviews is that, unless we find ways to build functional health systems in fragile and failed states, it will be harder to make further progress on key global goals, such as the reduction of maternal and child mortality, as well as to protect the world from new infectious disease outbreaks. It is important to understand the context that faced the new government and its partners in early 2002 in Afghanistan because success was by no means inevitable. After many decades of conflict and instability and the reign of the Taliban, which had sought to impose a very strict interpretation of Islamic laws on the country, by the end of 2001, the human and physical infrastructure of the country was in ruins. Additionally, the health system in Afghanistan was highly dysfunctional; girls and women were banned from education and the workforce and their access to health services was highly restricted. Outbreaks of cholera, measles, polio, diphtheria, and even rare micronutrient deficiency disorders such as scurvy, were common.3Salama P Leaning J Borrel A Responding to the public health crisis in Afghanistan.in: Levy B Sidel V Terrorism and public health. Oxford University Press, 2003: 136-152Google Scholar Child and maternal health indicators were very poor; one study suggested that maternal mortality in the remote north-east of the country was one of the highest ever recorded worldwide.4Bartlett LA Mawji S Whitehead S et al.Where giving birth is a forecast of death: maternal mortality in four districts of Afghanistan, 1999–2002.Lancet. 2005; 365: 864-870Summary Full Text Full Text PDF PubMed Scopus (171) Google Scholar While there was no absolute shortage of doctors, there was a shortage of midwives and nurses.3Salama P Leaning J Borrel A Responding to the public health crisis in Afghanistan.in: Levy B Sidel V Terrorism and public health. Oxford University Press, 2003: 136-152Google Scholar Given the volatile political and security context and the state of the health system after the Taliban rule, a reduction of mortality in children younger than 5 years of almost 30%, during the subsequent decade, and a maternal mortality reduction likely to be of a of a similar magnitude to those of child mortality, might seem surprising. In fact, the health sector outcomes described in Akseer and colleagues' Article were the result of deliberate choices made very early on during the post-Taliban period, driven by analysis of lessons learned from other post-conflict experience, and based on some sound principles. These drivers have been reviewed in detail elsewhere5Dalil S Newbrander W Loevinsohn B et al.Aid effectiveness in rebuilding the Afghan health system: a reflection.Glob Public Health. 2014; 9: S124-S136Crossref PubMed Scopus (18) Google Scholar but included a commitment to ensure the health priorities responded to the disease burden in the country; a focus on building confidence in the public health sector by implementing rapidly, and at scale, some major programmes (eg, national vaccination campaigns); the development of a standardised basic package of primary health-care services; the decision to focus the role of the government on stewardship and setting of standards (given the capacity gaps in the Ministry of Health and the likelihood that service delivery of the public sector would have taken many more years to reach scale); the decision to allow international and national non-government organisations to implement this basic package according to Ministry of Health guidelines (ie, contracting out); a strong commitment to monitor and evaluate and to accountability for results; sustained political commitment and leadership within the government; and a small group of strong and cohesive international partners in the UN, non-governmental organisations, and the donor community that supported this approach consistently over a decade. Importantly, the Ministry of Health and partners recognised that maternal mortality was a key priority in its own right and that it would become a key gauge of the overall functionality of the health system. This recognition led to a major focus on recruitment, training, and deployment of community-level midwives. Certainly, there is much more to do to secure the gains made in Afghanistan. A focus on newborn mortality, the other major remaining causes of mortality in children younger than 5 years including diarrhoea, pneumonia, geographical equity of service delivery, and quality of care, is certainly needed. A renewed and expanded focus on addressing malnutrition in a multisectoral manner is also urgently needed.6Varkey S Higgins-Steele A Mashal T et al.Afghanistan in transition: call for investment in nutrition.Lancet. 2015; 3: 13-14Scopus (16) Google Scholar Additionally, addressing the social determinants of poor health will remain an intergenerational challenge. While sustainability of the service delivery model is a concern, given that the broader security and political context in Afghanistan is likely to remain very problematic for years to come and that the government will remain fiscally constrained, the international community should continue to support these health sector gains, which represent one of the few success stories in Afghanistan's post-Taliban history. In many senses, the Afghan experience can be regarded as one of the prototypes for what today we would call results-based financing. Additionally, this country case study exemplifies many of the broader development principles outlined in the fragile states guidelines from the Organisation for Economic Co-operation and Development and Development Assistance Committee.7Organisation for Economic Co-operation and DevelopmentPrinciples for good international engagement in fragile states and situations.http://www.oecd.org/dacfragilestates/the10fragilestatesprinciples.htmDate: 2007Google Scholar In particular, the need to take context as the starting point; to focus on state building as the central objective; to promote non-discrimination; to align goals against local priorities; and to act fast, but to stay engaged long enough to give success a chance, seem highly relevant. More effort should be made to formally evaluate and document such positive examples of health-care gains in fragile states for potential replication. And, during the period of the Sustainable Development Goals, if we are to prevent further division of the world into countries where people have access to primary health care and those that do not, and into stable states and fragile or failed ones, increasingly donors should reorient their financing accordingly. If Ebola has taught us anything at all, it is that supporting health systems in fragile states is clearly a global public health good that we ignore at our own risk. We declare no competing interests. Achieving maternal and child health gains in Afghanistan: a Countdown to 2015 country case studyDespite conflict and poverty, Afghanistan has made reasonable progress in its reproductive, maternal, newborn, and child health indicators over the last decade based on contributions of factors within and outside the health sector. However, equitable access to health care remains a challenge and present delivery models have high transactional costs, affecting sustainability. To maintain and further accelerate health and development gains, future strategies in Afghanistan will need to focus on investments in improving social determinants of health and targeted cost-effective interventions to address major causes of maternal and newborn mortality.