Health sector support project

Evaluation covered the period 1987-2/90. Due to the U.S. ban on travel inside Afghanistan by U.S. citizens, the primary implementing agency, Management Sciences for Health (MSH), has been operating out of Peshawar, Pakistan. This situation has had a serious detrimental effect on project monitoring, as well as on the project"s credibility among other health care donors. Nonetheless, MSH has managed the project well; activities are on schedule, and programs have been expanded in the three "Area Health Development Schemes" -- particularly in the Shura-e-Nazar and Hazarajat regions. In a short time, MSH has established more than 1,400 health posts and 120 clinics. These facilities, along with the multitude provided by other donors, are providing adequate health services to Afghanistan"s male population. Women, however, and to a lesser extent children, are not being reached, largely due to cultural constraints. MSH needs to increase its efforts to reach these groups, since maternal/child health care is the most needed intervention at this time. Working relations with the Ministry of Public Health (MOPH) of the Afghan Interim Government are cordial and appropriate, although an Afghan professional should be hired immediately to interface with the MOPH and other Afghan entities. The basic health worker (BHW) concept has been generally well received inside Afghanistan and by the MOPH, but the PVO and donor communities see the BHW"s as a potential danger to patients, since they use sophisticated medicines with only minimal training and operate without due supervision. The MOPH (with MSH assistance) should focus on training BHW"s in an effort to reach a maintenance level of 1,500-1,700 BHW"s and should develop traditional, hierarchical health systems within which the BHW"s can be supervised. More generally, competence-based training should be designed and certification provided for all levels of health workers. The major lesson learned is that it is possible to provide a seemingly significant amount of medical and health care to a country at war from operational bases outside the country. On the other hand, the quality and cost-effectiveness of this care can only achieve a mid-level plateau without moving the operation inside the country.