1. Structure of the Health Care System in Afghanistan
The Basic Package of Health services (BPHS) is offered in four standard types of health facilities below the level of the provincial, regional, and national hospitals (MoPH, 2005). The four standard types of health facilities are the health post (HP), basic health center (BHC), comprehensive health center (CHC), and District Hospital (DH). These services include outreach by community health workers (CHWs) at HPs, outpatient care at BHCs, and inpatient services at CHCs and DHs. In addition, services are provided through health sub-centers (HSC) to bridge the gap between HPs and other BPHS levels of service delivery and mobile health teams (MHT).
The provision of health services as mentioned above is in rural areas but there is not such system in Kabul city. There is only private health sector and tertiary governmental hospitals active in Kabul city and the access of poor people in urban areas is limited to those health facilities.
Afghanistan is committed to achieving Millennium Development Goal 5 which targets a reduction in the maternal mortality ratio (MMR) by 50 percent between 2002 and 2015, and further reduction to 25 percent of the 2002 level by 2020 (UNDP/GIRoA, 2008). Maternal and child health are strongly associated with the care received by women during pregnancy and delivery.
The infant mortality of 64 deaths per 1,000 births and an under-5 mortality rate of 83 per 1,000 births are still high [Afghanistan Mortalit survey].Early childhood mortality and infant mortality, in particular, are widely used indicators of a nation’s development and well-being. They improve understanding of a country’s socioeconomic condition, and they shed light on the quality of life of its population. Most important, childhood mortality statistics reveal the health status of children and are thus useful for informing the development of policy and health interventions that will promote child survival. Disaggregation of this information by socioeconomic and demographic characteristics further identifies subgroups at high risk and helps to tailor programs to serve these populations.
2. Introduction of the target area
The health infrastructure in Afghanistan damaged by years of conflict is gradually being re-established by the Afghan government with the help of the international community. The health services inherited at the end of 2001 were limited in capacity and coverage, and while theMinistry of Public Health, Afghanistan (MOPH) has shown leadership and started to implement the Basic Package of Health Services (BPHS) and Essential Package of Hospital Services (EPHS), the health status of the Afghan people is still not in a good condition. A high number of the population lacks access to safe drinking water and sanitary facilities (MOPH).
In urban centres, poor waste management practices and the lack of modern sanitation and sewage systems are the primary environmental factors affecting human health. Moreover, levels of air pollution particularly in peri-urban areas of the cities appear to be high. This is true of both the peri-urban and rural poor, who suffer from lack of access to safe water and basic sanitation.
Nearly 75% of the urban population, estimated at close to 5 million, may be living in slums. Afghanistan also has the highest rate of urbanization in Asia, 6% per year, which puts a high burden on the already weak service delivery in urban centers.
Rapid urban growth in a climate of economic and security constraints has resulted in that some residents in Afghanistan’s large cities living in overcrowded slums and underdeveloped areas. In these underdeveloped areas, health conditions and livelihood opportunities are poor. The proportion of peri-urban population in Kabul city increased. A remarkable proportion of district 5 are those who came from rural areas because of war and economic problems. Rapid urbanization amid economic degradation in the city and has resulted in an increased proportion of people living in poverty in the underdeveloped areas.Therefore, poverty has increasingly become a crucial problem in underdeveloped areas of the city leading to mushrooming of informal settlement where the poor and internally displaced persons (IDPs) find shelter. This has overwhelmed the environmental health resources. Because they are informal settlements and do not receive government services such as water, drainage, sewerage, and waste collection. Consequently, informal settlements are characterized by poor environmental conditions that predispose their inhabitants to poor health outcomes.
Access to improved sanitation in urban areas is restricted to only 21% of the households, and access to safe water is restricted to only 58% of the households (Icon-Institute, 2009), much lower than benchmark countries Safe water: [Nepal (89%), Bangladesh (80%)]; Improved sanitation: [Nepal (27%); Bangladesh (36%)]. (Urban Kabul Health Project, JICA)
Low-income households of urban Kabul are severely affected by high OOP (Out of pocket money) particularly for pharmaceuticals. The cost-effectiveness of health system is further reduced by poor access to water and sanitation, as well as low literacy rate that is associated with deficiencies in health seeking behavior.
The health system has begun the comprehensive task of rebuilding after several decades of war in Afghanistan, increasing isolation and the demise of its infrastructure.
According to the United Nations Children Fund (UNICEF) report in 2011, 48% of the total population of Afghanistan have access to safe drinking water, 37% have access to safe sanitation, 55% of schools have access to improved water sources and 50% of schools have access to improved sanitation.However a survey which was conducted by the Ministry of Public Health,(MOPH) Afghanistan and International partner organizations in 2010 documented improvements in access to clean water, sanitation, and electricity. According to that survey more than half of all households have access to improved sources of drinking water, though only one in five has improved sanitation facilities that are not shared with other households and about 40% of households have access to electricity.
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Kabul the capital city of Afghanistan has two independent Councils or administrations at once known as prefecture (rural area) and municipality (urban area). According to administrative definition Kabul City (municipality) has 22 districts (named from district-1 to district-22) whereas the Kabul prefecture has 15 rural districts .This city has been facing different challenges like overgrowing population and rapid urbanization. Situations of water and environmental sanitation and hygiene have deteriorated in the city; Kabul city was initially designed for the population of one million but is now home to population more than four million .
As a result of rapid urbanization in the context of economic and security constraints, the majority of peri-urban residents in underdeveloped areas of Afghanistan live in slums . This informal settlement and poor waste management cause severe health related problems in the area.The illegal status of the underdeveloped area in Kabul has hindered the expansion of municipal services to serve them. This has resulted in the poor being denied access to safe drinking water, proper sanitation and waste disposal.
Dewan Begi is an underdeveloped area located in district 5 of Kabul city .The estimated population of district 5 is around 150,000 and the estimated population of Dewanbegi area is around 12000 population. [ Central Statistic Office CSO] A large part of district 5 is underdeveloped area with informal settlement. At the same time, unprecedented numbers of internally displaced persons (IDPs) and refugees have overwhelmed much of the already fragile infrastructure of underdeveloped areas of the distinct, setting the stage for outbreaks of infectious diseases among local populations. The health facilities and private clinics data indicated that a high number of Dewan Begi residents suffer from different diseases and seek the health care from health facilities and private clinics. However it is assumed that many of them do not prefer to consult a doctor when their household member or child is sick because they are very poor and do not have financial resources. Most houses in the area are made of mud. Majority of the people who are living in Dewan Begi area are poor.Due to those mentioned health problems in the country, Kabul the capital city of Afghanistan is also faced to high maternal mortality and due to an acute lack of even basic prenatal and obstetric healthcare mainly Afghan women and infants are facing some of the highest maternal and infant mortality rates.
Like other countries, lifestyle related diseases (Cardiovascular diseases, Hypertension, Diabetus, etc) infectious and communicable dieseases increased in Afghanistan and those patients need countinous medical care, thus there is a need to establish such clinic in Dewan Bigi area which will help in this regard.
Due to mentioned health problems and location of mentioned area, the residents need a health facility to seek health services and there should be a follow up system for those patients who are living in the area.Complicated patients should be reffered to other specialized health facilitis,
Representatives of Dewanbegi in the 5th district of Kabul met, complaining the lack of basic health facilities. Member of the assembly was Mr. Ziaulladin Wakeel Guzar of the local public administration delivered their request to Afghanic organization for building of the mentioned clinic. The participants pleaded for the erection of an outpatient clinic privately initiated and organized by self-help of the affected inhabitants.
3. Implementing Agency
The concept to establish the clinic is from Afghanic and different people promised to help to build the clinic.
Afghanic already started first fundraising activities in Germany to collect money given by private individuals. Afghanic is officially registered by German law and annually controlled by the authorities of the German State of North-Rhine Westfalia in Bonn. The two board members of Afghanic, Dr. Yahya Wardak who is living and working for three years in Kabul city and Dr. Juergen Kanne, former member of the German Partnership and Lecturer Team at the Faculty of Economics, Kabul University (1969-72) supported by its local representative, guarantees that each contributed Euro and Afghani will be put into the Dewanbegi clinic project without receiving any salary or other amendments. Additionally the budget of this entire project will be controlled by Dr. Ghanie Ghaussy, Member of the Board of Directors of Da Afghanistan Bank (Central Bank) and Chairman of AMZ-Foundation. Also these controlling activities are not being paid by Afghanic or any other organization.
4. Organizational Structure
The clinic will be focused on the basic need of health services for the 12,000 families of Dewanbegi. Many of them came to Kabul as refugees from other provinces. Most of them have many children – on average five. There is neither elementary school nor a health service available. In case of illness or prenatal problems the people have to go a long way to search for a doctor.
Dewanbegi clinic will provide the following health service:
- General Medical Services ( Internal Medicine ) according to the German system of “Hausarzt-Service” (“house-doctor”)
- Pediatric Medicine
- Gynecological and Obstetric Care
- Provision of Dental service
- Laboratory, Ultrasound and X-ray
All care will be provided on the basis of effective costs and non-profit services. There would be a record and follow up system for each patient. The local staff and Afghan doctors who are living in Germany will work in this clinic. The German and Afghan doctors who are living in Germany will come to Kabul during their holidays and they will provide on the job training for the local staff.
5. Budget and Financing
All costs for the purchase of land, construction of the building and purchase of medical and other durable equipment have to be financed by private and public donations. The ongoing costs for medical staff salaries, support staff salaries including security service, clinic supplies and utilities, training program supplies and utilities have to be covered by the patients being treated on comparable cost basis of about USD 2 per visit plus medicine costs. The “Center for International Migration and Development” (CIM) in Frankfurt is financing half of the project which enabled Afghanic to start construction works for building the mentioned clinic.
6. Project realization and time schedule
About 2020 square meterland purchased in Diwanbegi area of district 5 of Kabul city and the discussion is ongoing with the construction engineers and architects and the construction work of the clinic would be started shortly. This non-profit health-care-project will be started as a pilot project; other similar projects in other parts of Kabul and/or Afghan provinces might follow thereafter. Donations are most welcome.
Afghanistan: Dewanbegi-Clinic, 4th Street, 5th District, Kabul
Digital: 020 25 61 006, Phone: 07560146440, Mobile: 0706320844
Germany: Afghanic e.V. Office in Bonn
Kabul/Bonn, Nov 2013, Dr. Yahya Wardak, Chairman & Dr. Juergen Kanne, Member of the Board