Following decades of war and neglect, the reconstruction of the health system in Afghanistan is in full swing since 2002, thanks t- considerable efforts undertaken by the Ministry of Public Health (MoPH), donors, various experts, and national and international NGOs.
The first priority was developing basic health services throughout the country, namely the Basic Package for Health Services (BPHS), and the second was the reorganisation of the hospital system. At the same time, research has been carried out on financing systems and the quality of services provided.
Different quality approaches are currently being tested within the health sector and this article aims t- provide an overview of how some of these initiatives are progressing. Our analysis is based on interviews with key interlocutors in Kabul in July 2005 and a number of documents1. This research comes within the wider framework of a cross-sector study which is being carried out by Groupe URD on the transition from emergency t- development in Afghanistan. Its purpose is t- identify and describe important changes that are taking place in various sectors, t- evaluate their impact and share the lessons learnt with the various stakeholders concerned by this subject.
1 MoPH hospital policy and the issue of quality
The MoPH in Afghanistan determined a certain number of priorities for the health sector in response t- people's needs. In March 2003, a MoPH working group was commissioned t- design the BPHS, on which the primary health care system is based (Health Posts and Community Health Workers at village level, Basic Health Centres, Comprehensive Health Centres, and finally District Hospitals at the top). When necessary, these health centres should be able t- rely on the support of highperformance referral hospitals (Provincial and Regional Hospitals) (MoPH, 2003).
In March 2004, another working group, Hospital Task Force, drew up a hospital policy, the Essential Package of Hospital Services (EPHS), in the aim of improving (i) hospital management, (ii) the integration of hospitals int- the health system, and (iii) the quality of services provided (MoPH, 2005).
This policy was drawn up on the basis of a study which highlighted six main weaknesses in the hospital system:
- Uneven distribution of hospitals throughout the country, hence the inequitable access t- healthcare which essentially affects the rural communities. Furthermore hospitals receive to- large a share of human resources and funds in comparison t- primary health services.
- Lack of health care standards, hence poor quality.
- Insufficient management capacity in hospitals, hence problems with efficiency, supply and maintenance.
- The hospital system is fragmented, poorly coordinated and is not integrated int- the health care system. This results in a lack of reference system and insufficient support for primary health care services.
- Insufficient funds hence the need for a user fee system which nonetheless ensures that the poor still have access t- health care.
- Insufficient qualified staff, which is particularly problematic for female staff and in remote areas, making it difficult t- provide a 24-hour service and for women t- receive treatment.
The objective of the EPHS is t- define the necessary services, staff, equipment and drugs that must be provided by health centres at all levels (district, province, region). Three priorities have been established:
- Benchmarks will be established for both hospital management and health care. Six domains will be covered: responsibility towards the community, patient health care, leadership and management, human resources, management systems, context.
- Hospital councils will be created with volunteers from the community in order t- ensure a link between the management team and users.
- An accreditation system will be set up in order t- ensure that all hospitals are providing quality basic health care. Some elements related t- quality have been proposed, taken from a report issued by the Ministry of Health of Tanzania, including: quality of consultation, effectiveness of treatment, necessity of treatment, continuity of treatment, patient and community satisfaction, efficiency, accessibility (Newbrander, 1999). These quality issues have not yet been finalised and are currently the subject of further study within the MoPH. 1 See list of main interlocutors met and documents consulted in the appendix.