| Efforts to revive Afghanistan's dilapidated
health system and provide increased access to basic medical care
have improved mortality rates since the fall of the Taliban in 2001,
but staffing and resource hurdles still remain.
 When
coalition-backed forces invaded in 2001, Afghanistan had some
of the highest infant, child and maternal mortality rates in the
world. Largely preventable diseases such as respiratory infections,
measles and malaria were the leading causes of childhood death.
After the toppling of the hard-line Taliban, nongovernmental
organizations (NGOs) under the new Afghan government's supervision
began providing standardized health services covering maternal
and newborn health, child immunization, nutrition, treatment of
communicable diseases, mental health and disabilities.
While there are still many areas of Afghanistan where medical
aid is difficult, if not impossible, to obtain, preliminary results
in a Johns Hopkins University study show that the infant mortality
rate has declined to about 135 per 1,000 live births in 2006,
from an estimated 165 per 1,000 in 2001.
Commissioned by the Afghan Ministry of Public Health, the survey
found the number of women receiving prenatal care increased to
30 percent in 2006 from 5 percent in 2003.
"In any other country you would say that's a miserable number,
but it's a big start in three years' time," said Gilbert
Burnham, professor of international health at the Johns Hopkins
Bloomberg School of Public Health.
However, any gains made in the health sector are threatened by
a combination of security issues, limited infrastructure and lack
of skilled human resources, especially women health workers.
Even basic equipment and personnel needed to run facilities are
in short supply, said Anne Ritcher, a certified midwife who worked
to train midwives in Afghanistan through USAID.
"In Afghanistan, you have to think about something as simple
as clean water," Ritcher said. "Local hospitals are
not set up. They don't have IVs and do not have the capacity to
do blood transfusion. The loss of time transporting them to a
provincial hospital is critical."
The education system under the Taliban regime, which excluded
women from school, exacerbated the problem of qualified health
workers, said Sallie Craig, program director for Management Sciences
for Health working with USAID in Afghanistan.
Craig said the general population doesn't have the prerequisites
to become skilled health workers, and it could take years to bridge
that gap.
Various aid organizations have set up programs to encourage women
to become trained health workers, as there is a strong cultural
preference for female practitioners to treat female patients.
 USAID
created an accelerated 18-month midwife training program, which
has graduated more than 800 midwives as of 2006.
Providing maternal care to women in rural areas is a challenge,
said Dr. Hemlal Sharma of the UNCIEF Afghanistan Country Office.
"Various actors, including the [nongovernmental organizations],
have relaxed the entry criteria for remote areas and are giving
higher salary for females who are willing to work in remote areas,"
Sharma said.
But the impact of these local efforts remains difficult to measure.
Afghan-American filmmaker, Sedika Mojadidi, whose documentary
Mother Afghanistan put her in contact with Afghan health facilities
in 2003 and 2005, said it is difficult to measure success in Afghanistan's
health system because of a lack of consistent data.
"There is so much health assessment that needs to happen.
A lot of money is being poured into health sectors and the results
are not consistent with the talk, reports and surveys," she
said.
Dr. Douglas Huber, who assisted USAID in implementing family
planning practices in Afghanistan, said the success of Afghanistan's
health system depends on continued funding, especially from international
donors.
"Political will from the international community may be
the biggest vulnerability," and a reduction in funds would
lead to a reversal of the country's health care progress, he said.
Community-based approach
Reaching out to both men and women and finding ways to integrate
health education into communities has been essential for nongovernmental
organizations.
A health-based literacy program called Learning for Life was
set up to train female participants to be health workers and midwives
in their own communities. Craig said local people help to select
these women to give basic first aid, contraceptives and referrals
at the community level.
"Having these women out there is low-cost intervention"
said Craig. "These women are pleased to have this recognition,
very proud. People are starting to get the sense that life is
not totally out of control but starting to plan for the future.
This is a big change."
 Huber,
who worked with USAID, said mullahs and other influential people
at the local level have showed a willingness to help promote health
awareness.
"Mullahs were very receptive and in some cases very eager
about promoting family planning strategies, saying they would
use Friday prayers to talk about things like birth spacing and
contraceptive use," he said.
Huber recalled another mullah keeping track of when his wife was
due for her next dose of injected contraceptive in a notebook.
"When there was a good understanding of safety and how [contraceptives]
work and how this could fit to promote healthy children and mother
in accordance with the Koran, a lot were neutral or agreeable,
" Huber said.
Organizations have also tried other forms of communication, using
radio to spread the word about health services, especially in
rural areas. Ron Waldman, a professor of public health at Columbia
University said mobile teams and local centers are part of the
health ministry's plan to increase access in remote or insecure
areas.
Efforts to supply medical care to people in all regions have
been hampered by security risks, especially in the southern and
eastern portions of the country where the Taliban resurgence has
focused.
There has been a rise in attacks against aid workers with 28
NGO workers killed between January and August of 2006, compared
to 31 humanitarian assistance workers killed in all of 2005.
"NGOs report having problems in recruiting and keeping staff
in insecure areas because of threats, intimidation and these direct
attacks. Health facilities are being closed down following threats
and service providers have been kidnapped and killed," said
Sharma of UNICEF.
Amid the continued violence and limited physical medical care,
the efforts to help heal the psychological scars of 20 years of
conflict have barely begun.
The World Health Organization's Assessment Instrument for Mental
Health Systems in 2006 reported Afghanistan only had two psychiatrists
for a population of 25 million, despite the inclusion of mental
health services in the official package of basic health services.
About 72 percent of the Afghan people suffer some kind of psychological
stress, according to a 2004 Journal of the American Medical Association
study.
Both the mental and physical care of the Afghan population will
need to rely on the work of aid organizations, but officials know
a multi-sector approach is needed to build up a domestic system
of health care and to ensure the slow rebuilding process continues.
-- By Amanda Cassandra, Online NewsHour
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