Country profiles

Afghanistan

Overview

Afghanistan has a land area of 652 225 km². Large areas of the country, particularly in the north and the east, are mountainous with altitudes reaching 8000 meters. Many roads and tracks become impassable during the winter months. The most recent population census taken was in 1979 and placed the population at 15.5 million.In 1996, the United Nations estimated that approximately 2 million refugees were residing in northern Pakistan. At the same time an estimated 1.5 million Afghan refugees sheltered in the Islamic Republic of Iran and elsewhere. However, the United Nations High Commission for Refugees reported that a significant number of refugees have returned to their places of origin in Afghanistan since 1996. Repatriation is voluntary and is still under way in many places. The United Nations projected population estimate for 1998, based on the census of 1979, was 21 million. The urban and nomadic populations constitute 25% and 3.6% of the population, respectively; more than half of the urban population lives in the major cities: Kabul, Jalalabad, Kandahar, Mazar-i-Sharif and Herat. The proportions below 15 years and above 65 years of age were 45.6% and 3.0%, respectively.(1995)

Afghanistan is one of the world’s least developed countries with an infant mortality rate of 165 per 1000 live births and life expectancy is 43.5 years ( 1996). Also, the total adult literacy rate and adult female literacy rate are 27% and 13.5% respectively(1995,), and as many as 80% of the population live at subsistence level .Both the crude birth rate and the crude death rate are very high and were estimated at 48 (1995) and 28 (1995) per 1000 population, respectively. The infant mortality rate is also very high and was estimated at 165 per 1000 live births (1995). Maternal mortality is estimated at 170 per 10 000 live births (1996). Children under 5 years of age have a mortality rate of 250 per 1000 live births (1995).

The leading causes of mortality and morbidity in recent years are communicable diseases such as diarrhoeal diseases, acute respiratory infections, tuberculosis, malaria and leishmaniasis; intestinal parasites; and noncommunicable diseases such as diseases of the circulatory system. Injuries and malnutrition are also common.

Although data available are neither complete nor accurate, estimates suggest that about 70% of the population in urban areas and 38% in rural areas are covered by local health care. Safe water is available to about 38% of the population in urban areas and to 17% in rural areas. The environmental health situation in Afghanistan is deplorable, and it is estimated that only 7% of those residing in urban areas have safe sanitary disposal facilities.

Dari and Pashto are the two national official languages.

The primary health care strategy was endorsed in 1979. The strategy sets the following objectives:

• to increase accessibility and efficiency of the health care delivery system

• to strengthen the functional integration of preventive and curative services

• to adopt the team approach and strengthen the district health system

• to improve public awareness about health and healthy lifestyles

• to improve the development of human resources as regards planning, production and use by more equitable distribution of qualified personnel

• to reallocate resources more favourably towards primary health care.

The health care system has five levels, defined by their capacities to deliver health services, from village, district, provincial and regional up to central level. At village level, there are the village health workers and traditional birth attendants, with a feldscher [male nurse] at the subcentre or health post. These are linked to basic health centre,at the district level, headed by a physician, and some districts have a district hospital with 10-20 beds.. The health system infrastructure is a pyramid of referral institutions from health posts in the village to basic health centres, and so on to provincial, regional and central hospitals. At each level, they offer referral services and, as appropriate, provide primary and specialized outpatient services. There are limited maternal and child health services and some family planning services in the subcentres and basic health centres.

In 1987, there were 13 subcentres, 107 basic health centres and 172 hospitals. Because of the present civil unrest, not all health centres and hospitals are functional; and of those that are, some are operating with reduced capacity. Of 6246 beds in the whole of Afghanistan, 50% are located in the central region, of which 90% are in Kabul city alone. This gives a ratio of 11.2 beds per 10 000 population in Kabul city against a ratio of 2 per 10 000 population for the rest of the country.

In 1998, there were 2228 physicians working for the Ministry of Public Health and for nongovernmental organizations, giving a rate of 1.1 physicians per 10 000 population. This compares to the figure for 1984 when there were only 1369 physicians with a rate of 0.86 physicians per 10 000 population. There are also 2976 nurses (1.4 nurse per 10 000 population), 654 midwives (0.3 midwives per 10 000 population), 135 dentists, and 755 vaccinators.

There is an acute imbalance between the geographical distribution of physicians and the size of the population they are expected to serve, and even so, the proportion of physicians to the size of the population within each region is far from satisfactory. In 1984, 58% of physicians were concentrated in Kabul province, reaching less than 12% of the population, whereas in 1990, 94% of physicians were in urban areas, reaching only 18% of the population.

With a view to improving the operational efficiency of primary health care services, the Ministry of Public Health has begun to implement the district health system based on primary health care in many districts. Until now, 280 districts out of a total 330 districts are covered with some components of primary health care. In 1994, a policy of decentralization and delegation of financial and management responsibilities to regions and provinces was introduced. Operationally, the country is divided into seven regions-northern, north-eastern, central, southern, south-eastern, eastern, and western.

Monitoring and evaluation of health programmes in Afghanistan have always been very poor. However, regionalization and the establishment of regional and provincial management teams in the Ministry of Public Health, with the technical support of WHO, have made significant changes. However, the limited resources of the Ministry of Public Health are a major obstacle to monitoring and evaluation procedures.

Health personnel are state-employed; a few have private practices in addition to their public employment. Private practice is concentrated mainly on running pharmacies; 92% of pharmacies and 30% of laboratories are privately owned. Nearly two-thirds of physicians’ private clinics are situated in Kabul and the provincial capitals.

The provincial health profiles presented by the regions during a health sector planning workshop in 1998 demonstrated wide ranging levels of organization and management of health services; human resources and their distribution; number of health facilities by type and the package of services they provide; and the availability and accessibility of primary health care services.

The education sector is taking an active part in health education in schools; primary-level and secondary-level curricula have been revised to incorporate information on health matters. The Ministries of Agriculture, Information and Broadcasting, and Planning contribute to promoting people’s health, and the Ministry of Planning ensures that health goals are incorporated into socioeconomic development plans. However, no adequate mechanism exists to ensure systemic analysis and monitoring to show the impact of these actions this on health.

MENTAL HEALTH

Any description and discussion of mental health care in Afghanistan have to keep in view the sociopolitical realities of the country. Nineteen years of fighting have ravaged the whole country, and death, disability, destruction and disease have run riot beyond description. The whole social and family structure has been affected. External and internal migration of millions of Afghans have helped make the country one of the poorest in world. The major mental health needs of the population are those arising from the war, those related to refugee status and drug dependence.

The treatment facilities in the country consist of:

• Kabul Psychiatric Hospital.

• This is a 50-bed short-stay hospital, with 30 for male patients and 20 beds for females. It is located in an old building about 5 km from the city centre. Annual admission to the hospital is around 650 patients. Yearly outpatient attendance is estimated at 800, and the number of psychiatrists working in the hospital is 11, one whom is a female doctor.

• Marastoom Asylum. This is a 20-bed hospital, supported by the Afghan Red Crescent Society, which provides care for 200 chronically mentally disordered patients, including the mentally retarded and drug-related psychosis patients. No clear information is available.

• Drug dependent Rehabilitation Hospital. This hospital was started in 1990. Currently, there are 10 beds, of which two are for female patients. The annual admission is estimated around 700 patients. The major drug dependence is heroin.

• Community mental health centres. There are four centres at Wazir Akbar Khan, Katre Parwan, Khosal Miria and Alandin. These centres are presently not functional.

• Ali-Abad Hospital. There are only 5 beds for psychiatry in this general hospital of 60 beds. Annual admission is estimated at 420 patients.

• Jalalabad. There are two centres for mental health care. The university hospital has 10 beds, and there are 25 beds in the general hospital. The total outpatient load is around 5000 cases per year, while admissions are estimated at 650 per year.

• Mazar-i-Sharif. There is one mental health centre in the general hospital. The outpatient register showed 2119 cases in 1998, while 69 patients were admitted. Four beds are available for male patients, but nothing for females. There are three doctors working in this centre.

The above information has been collected from regional and provincial health profiles prepared in 1998.

There is extreme shortage of all categories of trained mental health professional. There are only a handful of fully trained psychiatrists with a postgraduate degree of diploma qualification. Doctors working as psychiatrists have been trained for short periods abroad (Poland, Sudan, India) or have had in-service training within Afghanistan. Those serving as psychologists have a bachelor’s degree in psychology from Kabul University. In 1990-91, a one-year in-service training programme for psychologists in mental retardation was carried out. In 1996, a three-month diploma on mental health was conducted in Mazar-i-Sharif.

There was undergraduate medical education, which consisted of five years of full-time classwork and practical training followed by one year of rotating internship. The training in behavioural schemes, psychiatry and mental health consists of:

• 18 lectures in each of the first and second semesters in first year on behavioural sciences

• 18 lectures in each of psychiatry and neurology during the fifth year.

• two weeks of clinical attachment in each of psychiatry and neurology at Ali Abad Hospital

• one month internship in psychiatry.

Postgraduate mental health training is not available in Afghanistan for any category of mental health professional.

A committee set up by the Ministry of Public Health drew up a national mental health programme for Afghanistan. The programme was discussed and adopted at a national workshop for mental health held in Kabul in 1987.

The national mental health programme has the following objectives: provision of mental health care to all the population; integration of mental health with primary health care; community participation; and services for special groups, especially those affected by war. The document outlines services, training, administrative strategies and approaches for promotion of mental health and provision of services for the war-affected population.

A large number of doctors and other health personnel have undergone short-term training in basic mental health care. Many workshops, seminars and group educational activities have been carried out for various categories of personnel on various mental health and substance-abuse related topics. Training programmes for non-health personnel such as teachers, school principasl, youth leaders, volunteers and community leaders have also been organized from time to time.

Two mental health manuals were prepared in Dari for primary health care doctors and other staff in 1998.

The overall mental health services in Afghanistan are very poor. However, mental disorder was recognized as a major public health problem during the health sector planning workshop in 1998. There are few nongovernmental organizations supporting some centres throughout the country. The capacity of the Ministry of Public Health is very limited. In addition, the magnitude of the problem is not known because of lack of information. In many regions, there are one or two centres where outpatient activities are conducted. WHO provides some mental health drugs to the Ministry of Public Health. Although new facilities were established in the 1980s, their services have been deteriorating year after year. Most of the assistance from international or local aid agencies was never passed to mental health care services.

The severe shortage of trained key mental health professionals to take up the role, the extremely limited facilities, poor equipment and drug supplies and the prevailing socioeconomic circumstances are the major hindrances to the development of mental health services.

As part of rehabilitation and revival of the mental health programme, in 1996 a three-month long diploma course in mental health was organized and conducted with the support of WHO in Afghanistan for 10 physicians. A total of 10 physicians (7 males and 3 females) successfully completed.

The objectives of the diploma course on mental health were:

• to train a core group of general practitioners from different provinces of Afghanistan in mental health and common psychiatric illnesses

• to initiate the first step of integration of mental health into the primary health care system through training of these general practitioners, who would then function as trainers themselves

• to introduce the basic approaches to community mental health and psychiatric epidemiology to this core group

• to prepare the basic necessary human resources for establishment and/or revival of a minimum number of mental health facilities in the country.

The course covered the following:

• knowledge, attitude and practice about mental disorders

• problem-solving skills

• research methodology

• interviewing/clinical skills.

This training course achieved its main objectives as follows. Ten general practitioners from different provinces were trained as a core group of mental health professionals. The participants are equipped with the knowledge of approaching the cases such as interview, history-taking, diagnosis and finally case-management. Basic community mental health principles were introduced to the group. The first step toward integration of mental health services into the primary health care system was taken. The comparison of pre-training and post-training evaluation results were highly significant.