AF PHJAfghanistan Journal of Public Health

Acceptability of an Afghanistan-Tajikistan Cross-border Health

: Towards Increasing Transparency and Integrity in the Ministry of Public Health in Afghanistan

among Males in Kabul, Afghanistan

Current Literature

Policy BriefHealth Challenge in Afghanistan

News: Public Awareness Campaign

Report

: Global Health 2035: The Afghanistan Context

Perhaps the most compelling sense of

Articles

Volume 2 Issue 1 January 2014

2014 Afghanistan National Public Health Association (ANPHA)

All rights reserved.

The views expressed herein are of the authors and do not necessarily represent the views of ANPHA.Copying and/or transmitting portions or all of this work without permission may be a violation of applicable law.

AFJPH Vol. 02 Issue 01 January 2014

Table of Contents

Abdul Alim Atarud, MD, MPH . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Page 2

Abdul Tawab Saljuqi, MD, MPH . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Page 3

Sue J. Goldie, MD, MPH . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Page 5

Gijs Walraven, MD, MPH, PhD Aziz Baig, MD, MPHJohn Tomaro, MPH, PhD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Page 8

Ahmad Shah Salehi, MD, MScAbdullah Fahim, MDCaroline Fitzwarryne, BNurs, MA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Page 16

Khalil Ahmad Mohmand, MD, MBA, MPH

Ahad Bahram, MD, MBA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Page 21

Shams Rahman, EMBA, MPH, MD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Page 26

Policy Brief. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Page 30

News. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Page 32

Report. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Page 33

Jennifer S. Edge, MScCherie L. Ramirez, PhDChristen S. ReardonAbdul Tawab Saljuqi, MD, MPHSue J. Goldie, MD, MPH . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Page 37

1 AFJPH Vol. 02 Issue 01 January 2014

Abdul Alim Atarud, MD, MPH11

ear Colleagues,I am very pleased and honored to be

the president of a professional, academic, and voluntary association, the Afghani-stan National Public Health Association (ANPHA). I would like to thank all AN-PHA members, particularly members of the Executive Board, for their efforts and endeavors. I am keenly looking forward to our teamwork in our advocacy efforts and working together toward establishing a healthy society.

ANPHA would like to congratulate the Afghanistan Ministry of Public Health

(MoPH) for its achievements in the last decade, particularly in its efforts to expand access to primary healthcare services, re-duce maternal and child mortality and ultimately increase life expectancy. The efforts over the past decade have led the health sector to prepare for epidemiologic transition, recognizing that disease pattern, disease burden, and demographic changes are essential indicators for strategic in-terventions in the policy arena. ANPHA would be pleased to provide expertise and professional input to the MoPH in the ar-eas of research, policy formulation and strategies design. Our journey is long and more needs to be done. We believe that as a civil society organization, ANPHA has been able to provide constructive advice and consultation to the health sector of Af-ghanistan that has been clearly welcomed and largely accepted and applied by the MoPH.

ANPHA is proud to publish the sec-ond issue of the Afghanistan Journal of Public Health (AFJPH), representing the thoughts, ideas, and evidence-based re-

D

2AFJPH Vol. 02 Issue 01 January 2014

and advocates. I am grateful to the efforts our Editor-in-Chief, Dr. Tawab Saljuqi, who worked tirelessly to solicit a broad range of submissions and coordinated the essential but challenging process of peer review.

I would also like to express our sincere gratitude to the Harvard Global Health In-stitute (HGHI), and its faculty director, Dr. Sue J. Goldie, whose professional support over the last three years has tremendously improved the quality of our journal.

I believe that ANPHAs members and their interest in our cause is what makes ANPHA such a strong and vibrant as-sociation. In conclusion, I would like to invite all public health professionals and advocates to join ANPHA and share their expertise to ensure attaining our shared vi-sion of a healthy Afghanistan.

Sincerely,

Abdul Alim Atarud, MD, MPHPresidentAfghanistan National Public Health Association

he most critical purpose for founding and publishing the Afghanistan Jour-

nal of Public Health (AFJPH) was to promote and sustain a culture of health research and publishing in Afghanistan. Therefore, I hope that in the years to come the journal evolves into an institution that encourages a culture of research and life-long learning, while serving to con-tinuously improve evidence-based public health practice and policy in Afghanistan.

During the past two years I have learned that attracting high-quality submissions is one of the greatest challenges facing an editor-in-chief of a new journal. There are three main reasons.

First, there are a greater number of estab-lished international journals than ever be-fore and competing with well-established journals for high quality manuscripts is

to publish their papers in well-recognized and widely distributed journals, for both dissemination purposes and for academic credit.

Second, a new journal does not yet have an established cycle of supply and demand. The AFJPH is inherently short on both, given the fragile nature of our

young pipeline of investigators in medi-cine and public health. It will take time to create a demand for locally-contextualized evidence and it will take time to build an adequate supply of locally-conducted re-search.

Third is the challenge of attracting good papers. In order to do so, we need to im-prove the process of submission, review-ing and publication. Some authors right-

Abdul Tawab Saljuqi, MD, MPH11

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fully have expressed frustration with the long period of time between submission

can be attributed to uncontrollable factors in the short-term, such as an inadequate number of submissions, short supply of peer reviewers, a need for several peer-re-view rounds for non-native English speak-ing authors, a lack of adequate technical infrastructure, and overall fewer resources than well-established journals. That being said, it is nonetheless an area we need to improve to meet expectations and to at-tract future authors.

-gurated during the second general assem-bly of Afghanistan National Public Health Association (ANPHA) in Kabul, Afghan-istan where the Minister of Public Health, Dr. Soraya Dalil called it a great achieve-ment. The ceremony was of great symbol-ic importance in that it demonstrated the support from both the governmental and non-governmental health sector for this initiative.

AFJPH also received a tremendously warm welcome by both national and in-ternational readers. The editorial team has received positive feedback and con-structive suggestions for improvement,

and some of which will be incorporated in upcoming issues. A highlight over the past year was the short editorial written by Dr. Richard Horton, the Editor-in-Chief of The Lancet, entitled The Real Meaning of Innovation: Mention the word Afghani-stan and one might conjure up images of terrorism, violence, and political mayhem. Western armed forces are now approach-ing the end of their latest period of mil-itary intervention, leaving a precariously prepared Afghan civil society to take over full governance of a country denuded by decades of colonial wars. But this com-monly pessimistic view of Afghanistan

the English-language Afghanistan Journal of Public Health was published. (1)

There is no doubt that without the sup-port of ANPHAs members and its lead-ership the launch and continuation of the

journal would have been impossible. A great amount of credit goes to Dr. Ahmad Shah Salehi, former President of ANPHA, and Dr. Alim Atarud, current President of the Association, for their thoughtful guid-ance.

Through the generous support of our colleagues at the Harvard Global Health Institute (HGHI), the journal has received membership into the Committee for Pub-lication Ethics (COPE) and received an ISSN number. Membership in the COPE is of particular importance for our new journal, and will guide us in meeting and managing ethical challenges that often ac-company early submission, peer review and publication efforts.

Thanks to The Eastern Mediterranean Association of Medical Editors (EMA-ME) and the World Health Organizations

-nean (EMRO) the journal was registered in the database of the World Health Or-ganization (WHO) and is indexed by the Index Medicus for the Eastern Mediterra-

few vital steps towards standardization of the journal and will make it a pioneer in publishing public health papers in Af-ghanistan. All of these efforts are critical

operation, the quality of service to our au-thors, and the credibility of the journal to

Afghan authors are investing in the fu-ture of the AFJPH, and continue to sub-mit manuscriptssome of which are published in this issue and some to be published in the upcoming volumes. I am proud to announce that this issue has more Afghan peer reviewers than before. We have strategically approached many Af-ghan public health experts to participate in the process of peer review in order to in-stitutionalize the culture of peer review in our local academic circles. Fortunately, we have attracted several excellent reviewers

the Eastern Mediterranean Public Health Network and Dr. Shams Rahman of the

South Florida.

AFJPH Vol. 02 Issue 01 January 2014

At the same time we have deliberately tried to expand our group of internation-al reviewers to include experts from all walks of public health. For instance, in order to have a peer reviewer with experi-ence in border health, we asked Dr. Ce-celia Rosales from the Mel and Enid Col-lege of Public Health (MEZCOPH) at the

on Afghan-Tajik border health. Similarly, we approached Saint Louis

-ment to review selected paperscollab-oration happened through the efforts of Afghan public health alumni who have

through the Fulbright Exchange program. As such, we warmly recognize the im-portance of contributions from Fulbright alumni in making this issue possible. Two of these alumni and members of ANPHA, Dr. Nasratullah Rasa and Dr. Mohammad Saber Perdes, facilitated the peer review process and communication with authors.

I would be remiss in not expressing my

public health professional knowledgeable about Afghanistans public health. During the second issue of the journal, she provid-ed invaluable assistance, reviewing every submitted article and providing advice on all aspects of the journals publication.

Last but not the least, I have to thank Dr. Sue J. Goldie, Director of the Harvard Global Health Institute, who has been a genuine partner from the start, engaging intellectually and pragmatically, offering encouragement throughout, and consis-

-ship, the HGHI community has generously shared their knowledge, helping us to build the administrative and professional capaci-ty required for the journals long term suc-cess. My visit to the Institute in 2013 and meeting with the team helped the journal staff to redesign the process of planning, reviewing and publishing, from copy ed-iting to automating the process of sub-mission through the installation of journal management software.

After this issue, Dr. Shams Rahman will take over the responsibility of Edi-tor-in-Chief of the journal. Dr. Shams has played an important role during the review process for this issue. His professionalism, experience in research and publication, as well as objective and critical thinking abilities, will allow the journal to contin-ue its path to publish high-quality, original papers from Afghanistan and around the

-der the leadership of ANPHA, and with the support of the many collaborations forged

4AFJPH Vol. 02 Issue 01 January 2014

in the last two years, will continue to im-prove the journal in content and structure.

In closing, I feel that my parting words as the originating Editor-in-Chief for the

winner who wants to use the few moments allocated for their speech to thank each and every person who had a hand in their successful journeyand yet in the end, because no words could do justice to each and every contribution, he or she simply thanks family, friends, and everyone. This journal and its success have been like an Oscar award for me and I will revere it and celebrate it for the rest of my life. There-

words to simply, and with the utmost sin-cerity, thank each and every one of you for supporting me in this endeavor.

Dr. Abdul Tawab Saljuqi, MD, MPHEditor-in-Chief The Afghanistan Journal of Public Health

1. Horton R.

[Accessed November 30 2013].

Sue J. Goldie, MD, MPH11

he public health community in Af-ghanistan has achieved a substan-

tial milestone with this second edition of the Afghanistan Journal of Public Health (AFJPH).

In the 2012 inaugural issue of the AFJPH, authors addressed the need for a strong national health system, covering issues ranging from service delivery and quality of care (1-3) to a robust health workforce (3-6). This focus was timely as new data on coverage achieved with the Basic Package of Health Services (BPHS) was released (7), a formal performance as-sessment using a balanced scorecard sys-tem was published (8), and the National Strategy for Improving Quality in Health Care was produced (9).

From a broader perspective, this focus was timely as well; strengthening nation-al health systems has emerged as a pri-ority on the global stage, gaining steady momentum over the last decade. While perspectives differ on the ideal conceptu-al framework, functional taxonomy, and performance measures, there is reason-able consensus on the general goals of a health system: 1) achieve better health for the entire population; 2) protect families

particular those who are poor or otherwise vulnerable; and 3) be responsive to peo-ples expectations (10).

In the context of rising rates of non-com-municable disease and widening health inequities, an increasing number of coun-tries aspire to achieve universal coverage; given the superimposed pace and scale of demographic changes, from population growth and aging to migration and rapid urbanization, the challenge to achieve this will be formidable. When coupled with the need for health systems to be context-spe-

capacity for both research and innovation (11), there is little doubt the attention to this topic was well warranted in 2012, and will continue to be in the future.

The contents of this second issue of the AFJPH are also of distinct contemporary

-cerns accompanying the complexities of

T

5

globalization, from the global transfer of risks to cross-border health challeng-es, to a pervasive epidemic of corruption and weak governance. These issues are emblematic of 21st century global health challenges confronting virtually all nation states, with causes and consequences trav-eling in both directions.

Consider tobacco-related disease and control, chosen to be highlighted in this is-sue of the AFJPH. In the very same month, halfway across the globe, the Journal of the American Medical Association, and substantial space in several other prom-inent journals, was devoted to the same topic, marking the 50th anniversary of

One would be hard pressed to come up with a more poignant illustration of the re-ality of shared problems (and necessity for shared solutions) than the prioritization of the same public health challenge in one of the most widely circulated journals in the North (published in one of the wealthiest countries in the world), with one of the

the South (published in one of the poorest countries in the world).

In this issue, Mohmand et al. report the results of a study conducted in Kabul to assess tobacco risk in males age 15 and older. While one in three participants

approximately half reported exposure to secondhand smoke (16). Rahman et al. draw attention to the increasing practice of hookah smoking, particularly in young people, compiling published information on its prevalence, determinants, and ad-verse health effects. Acknowledging the limitations of data availability and qual-ity, the authors pose important questions about public health messaging, social per-ception, and the role of tobacco regulation with respect to hookah use (17). While both articles represent examples of knowl-edge production, this issue also illustrates efforts to disseminate knowledge in order

-dition to a policy brief developed by AN-PHA, the annual report describes a media campaign designed to educate the public about the risks of tobacco, and efforts by the President, Dr. Alim Atarud, to advo-cate for tobacco control and regulation

(18, 19). Most recently, in Kabul on the 15th of December 2013, ANPHA and the Organization of Afghan Alumni (OAA), in cooperation with the Afghan Ministry of Public Health (MoPH), launched a cam-paign to promote awareness about the neg-ative effects of secondhand smoke.

Two events in 2013 represent good ex-amples of the local and global reach of

international gathering in February 2013 which included diverse stakeholders from more than 40 nations entitled Governance of Tobacco in the 21st Century: Strength-ening National and International Policy for Global Health and Development (20). The second was the release of a report in December 2013 entitled Global Health 2035: A World Converging within a Gen-eration from The Lancet Commission on Investing in Health (CIH) (21), marking the 20th anniversary of the 1993 World Development Report (22). What do these two events have to do with Afghanistan and how do they relate to this issue of the AFJPH?

-itor-in-Chief, Dr. Abdul Tawab Saljuqi, represented the journal at the two-day

-cliffe Institute for Advanced Study (20). The conference opened with Dr. Marga-ret Chan, Director-General of the World Health Organization describing the in-crease in tobacco use being observed in lower- and middle-income countries, even as a simultaneous decline is observed in wealthier nations (20). While country ex-periences were shared as a prominent com-ponent of the meeting, there was an em-phasis on what actions should be taken by the global community to both engage key stakeholders outside the health sector, and to support national efforts (see Box). Dr. Saljuqi brought Afghanistans perspectives

-bution to the collective conversation and the motivation to use the second issue of the AFJPH to direct attention to the public health threat of tobacco.

In the case of the second, the engagement of the Harvard Global Health Institute with The Lancet CIH provided an opportunity to discuss with our AFJPH partners how the health investment framework put for-

AFJPH Vol. 02 Issue 01 January 2014

6

ward in Global Health 2035 could be

Given the proximity of the report to the planned publication of the journal, includ-

an obvious vehicle to catalyze a discussion about relevancy and contextualization to Afghanistan (23). It is worth noting that

the sin-gle most important policy tool to reduce the burden of tobacco-related non-com-municable disease (21). Is this recommen-dation even relevant to Afghanistan? Re-markably, it is. It was just days ago that the lower house of parliament adopted a land-mark draft law banning smoking in public places and increasing the import duty on tobacco products by 50% (24).

Just a little over a month ago, World Bank Group President Jim Yong Kim declared corruption to be public enemy number one and described a prevention strategy with three key elements (25). First, we need to improve the way we share and apply knowledge about building institutions with greater integrity; second, we need to empower citizens with informa-tion and tools to make their governments more effective and accountable; and third, we need to build a global movement to pre-vail over corruption. In a provocative and forward-looking perspective, Salehi et al. discuss the attempts to increase transpar-ency and integrity in the MoPH in Afghan-istan from 2008 to 2011 (26). Consistent with the declaration by the President of the World Bank Group, Salehi et al. em-phasize the roles of both the government and the international community. The au-thors review several proposed strategies constructed through a collective process, including a formal working group in the MoPH to ensure transparency of anti-cor-ruption procedures, an initiative to assess the ministrys vulnerability to corruption, and an independent Health Complaints Of-

need to confront corruption and promote good governance, in individuals and insti-tutions, will not only be a prerequisite for improving health, but also for building a strong society. We know from the histor-ical trajectory of other fragile states that sustained growth and development will be nearly impossible without effective gover-nance, institutional credibility and public trust (27).

Finally, also in this issue, Walraven

et al. conducted a qualitative study of a cross-border health program in Gorno-Ba-dakhshan Autonomous Oblast (Tajikistan) and Badakhshan (Afghanistan) (28). The

AFJPH Vol. 02 Issue 01 January 2014

-tive efforts to rebuild the health system of Rwanda (29). A research agenda that places a fundamental emphasis on caring for the most vulnerable, that emerges from listening to the concerns and perspec-tives of patients and local providers, that

through open access publication, and that embraces the value of local creativity, is an agenda with the essential ingredients for principled partnerships and collaborative innovation (29).

This second edition of the AFJPH is to be applauded. As acknowledged by Dr. Abdul Tawab Saljuqi in his editorial, there has been and will continue to be a myriad of challenges in the quest to build a cul-ture of research and life-long learning (30). That being said, the tone of the edi-torials from both the AFJPH editor and the President of ANPHA is unequivocally pos-itive, and the praise for the journal from Dr. Soraya Dalil, the Minister of Public Health, equally supportive (19). Perhaps the most compelling sense of optimism emerges from considering just what the successful publication of this second is-sue representsa commitment to bring an evidence base to public health policy and practice in Afghanistan.

Afghanistan will add further complexity to what is already a fragile context. How-ever, transitions also represent windows of opportunity which can be exploited for change. While there is a potential for destabilizing turmoil, there is also a pos-sibility for transformation. In the spirit of the friendship between the communities of the AFJPH and the Harvard Global Health

-ity, persistence and passion of the public health community, both in and out of the country, will prevail.

Dr. Sue J. Goldie, MD, MPHRoger Irving Lee Professor of Public Health, Harvard School of Public Health; Director, Harvard Global Health Institute, Harvard University

1. Make tobacco control part of -

tions and other development agencies worldwide.

2. sector of a nation including

collectively to protect not only health, but also the harm tobacco places on their econo-my by passing laws to reduce use.

3. Place health as the centerpiece of any decision on a trade treaty that includes tobacco.

4. Diligently work toward a goal of reducing the prevalence rate of smoking to less than

2048.

description of the context alone provides insight into a broad spectrum of situation-al challengesphysical barriers to access, widespread poverty and illiteracy, lack of public services, and inadequate infrastruc-ture and human resources. The authors conducted focus group discussions involv-ing close to 200 health workers, commu-nity leaders, and patients to better under-stand Tajik and Afghan perspectives on

of the program. They found participants on both sides of the border perceived the

the political-social complexities, had sug-gestions about how to overcome structural and pragmatic barriers (e.g., cross-border security concerns), and provided ideas on how to better meet the needs of the com-

-nancing and social protection). This study is a particularly relevant example of an opportunity for shared learning, as elo-quently described by Binagwaho et al. in

1. Perdes M. Conference on Quality of Healthcare in Hospitals Stakeholders

2.

Afghanistan. 3. Carvalho N, Goldie SJ, Salehi A. The value of family planning for improving

4. Human Resources for Health in Afghanistan.

5.

Based Healthcare. 6.

7. MoPH. Islamic Republic of Afghanistan (2010) A Basic Package of Health Services for Afghanistan. Revised July 2010. Ministry of Public Health,

8.

10.

11.

12. . Jan 8, 2014. Vol 311;2. 13.

14. Warner KE. 50 Years Since the First Surgeon Generals Report on Smoking

15.

16. .

17. Rahman S. Hookah Smoking A Review of the Current Literature.

18. .

20.

21.

22.

23.

24. Smoking at Public Places Banned. . Available

25. World Bank.

7 AFJPH Vol. 02 Issue 01 January 2014

. Press Release available

26. Transparency and Integrity in the Ministry of Public Health in Afghanistan.

27.

~

28.

30. Afghanistan

8

Gijs Walraven, MD, MPH, PhD1 Aziz Baig, MD, MPH2 John Tomaro, MPH, PhD3

1

2

3

The challenges facing health authorities in the rural, mountainous province of Badakhshan in north-east Afghanistan are daunting. The population is extremely poor, largely illiterate, and widely dispersed. Mobility is restricted and transport costs are relative-ly high. Health facilities are few, ill-equipped, and staffed by a small number of poorly trained personnel (see Table 1). The Af-ghan government, with support from international donor agencies, contracted the Aga Khan Development Network (AKDN) to im-plement a health program in the province. The program, which started in 2003, follows the policy of the Afghanistan Ministry of Public Health (MoPH) that makes a single non-governmental organization responsible for planning, implementing, and moni-toring the health services in a district or province. This approach

-trol of resources, promote effective program management, and put the MoPH in a stewardship role. In this context stewardship can be characterized by providing vision and direction for the health

through regulation and other means.Health care is provided through a three-tier system, consisting

of:Community health workers (CHWs): one woman and one man per community with a population size of around 1,000. The CHWs are chosen by the community, native to

the local area and literate where possible.Basic health centers (BHCs) with outreach that concentrate mainly on outpatient services and normal obstetric deliver-ies; each BHC covers a population of 5,000 to 10,000.Comprehensive referral health centers (CHCs) with inpa-tient capacity and comprehensive obstetric services, in-cluding caesarean sections and blood transfusion services; each CHC covers a minimum population of 25,000 (1).

As of December 2010, the health system in the Afghanistan Ba-dakhshan border districts included 230 CHWs in 115 villages, 18 BHCs, four mobile units, and four CHCs. This network provides health care to an estimated 157,000 people, and delivers primary care interventions such as child immunization, micronutrient sup-plementation and nutrition screening, tuberculosis control, pre-natal, delivery, and post-partum care, family planning, and basic curative services, including integrated management of childhood illnesses (IMCI). Community nursing and midwifery schools lo-

provincial hospital, have been established and are being managed by AKDN.

Across the Afghan border in this region, on the other side of the Oxus (Amu Darya, Panji) River, sits Gorno-Badakhshan Au-tonomous Oblast (GBAO) of the newly independent Republic of Tajikistan (1991). Prior to independence, the Soviet health system

Introduction. Population health status, access to services, and health system capacity differ greatly in adjacent geographical areas of Afghanistan and Tajikistan. The objective of this study was to assess acceptability of participants in a cross-border health program in Gorno-Badakhshan Autonomous Oblast (Tajikistan) and Badakhshan (Afghanistan) introduced in 2009.Methods. A qualitative study utilizing focus group discussions (FGD) was designed using standard guidelines for staff selection and training, participant selection, question guide development, data collection protocol, and data analysis. Twenty-one FGDs engaged a total of 194 participants which included Tajik and Afghan health professionals, community leaders, patients and their family members.Results. The FGDs suggested that Tajik health professionals are willing to work across the Tajik-Afghan border to secure additional compensation, gain exposure to diseases not found in Tajikistan, and provide care to communities that share a common religion, culture, and history. Afghan patients seek Tajik professionals who work in the Afghan health system or make short-term visits into Afghanistan, as well as seek health care in Tajikistan that is not available elsewhere. Community leaders on both borders see great value in continuing and expanding the cross-border health program. Participants proposed measures that could enhance the programs effectiveness.Conclusion

Keywords: Health systems, Afghanistan, Tajikistan, cross-border health, qualitative study

AFJPH Vol. 02 Issue 01 January 2014

AFJPH Vol. 02 Issue 01 January 2014

successfully contributed to achieving relatively good health status for the communities in GBAO. Compared to its counterparts in nearby Afghanistan, the system in GBAO had a substantially high-er proportion of hospital beds, health facilities, and staff (with an estimated nine hospital beds, two doctors, and 16 nurses per 1,000 population) (see Table 1 and Map).

Health facilities and services in Tajikistan, once widely avail---

dies, and the outbreak of civil war (1992-1997). All public sectors, including health, were expected to transition to a more market-ori-ented system. This shift called for a transition from centralized

practice, the transition has not happened as predicted because the shift was imposed from outside and took place suddenly, leading

to a breakdown in the health infrastructure. Financial shortages have triggered a huge increase in out-of-pocket payments by pa-tients (estimated at 60-70% of the total healthcare expenditures), including informal payments to health professionals, whose sala-

have resulted in a concurrent decrease in health care access for the population (2, 3).

The Tajik government, recognizing the need to make structural

its vision of a sustainable, cost-effective health system accessible to all, the government promotes effective public health measures: enhancing primary health care by developing a Family Medicine speciality; reducing duplication in health service delivery and in-

of the health professionals; and involving the community in de-veloping and governing the system (4). Since 1997, AKDN has

Afghanistan

Afghanistan

133 181 28,100 228 213

6,507 604 1,400 54 116 64

Infant mortality rate (per 1,000 live births) 217 141 134 28 52

Under 5 mortality rate (per 1,000 live births) 323 n.a. 28 61

46 46 44 n.a. 67

100 n.a. 110 108

1 35 10 32 42 37

2 10 14 70 88

80 76 40 70

11 n.a. 13 n.a.

70 77 46 n.a. 100 100

0.3 44 48 36 36 70

0 16 37 83 83

0.1 0.1 0.2 n.a. 2.1 2.0

0.2 0.3 0.5 n.a. 5.0

0.2 0.3 0.4 n.a. 6.1

Gross average income per capita (US$) 80 n.a. 370 n.a. 700

capita (in US$)11.2 16.7 n.ap. 1.8 5.6 n.ap.

1

2

methodology was used.3

(both last accessed on 1st September 2011).

Walraven et al.

10

been involved in supporting the government health system in Gor-no-Badakhshan with technical assistance.

The Afghan-Tajik border has historically been regarded as a

Army in the 1920s, people crossed easily and often between Afghanistan Badakhshan and Gorno-Badakhshan, to visit markets and trade; marriages across the border were common. This changed when Tajikistan became a Soviet Republic, at which point the Tajik border became tightly controlled and virtually closed by Russian border guards. Following the collapse of the

River since 2003, the people on both sides of the border have begun to restore some of the former practices that served local community needs. Health programs in each location, however, have only been assessed within the capacities of the two distinct and separate states and their civil society institutions, not as a cross-border initiative. These efforts have produced very different results because the capacities of the key actors on both sides vary considerably.

In 2009, the cross-border health care approach was launched as an additional strategy for health reform, following an agreement between Afghanistan and Tajikistan government authorities (5, 6). Efforts since 2009 have shown that it is possible to recruit and post

health professionals from Gorno-Badakhshanwho speak the same language as their Afghan counterparts and share a common cultural backgroundto Afghanistan Badakhshan. In turn, teams of Tajik medical specialists have made short visits into Afghan border districts for medical consultations and surgeries. It has also been possible to treat some critically ill patients from Afghanistan

from Gorno-Badakhshan and Afghan Badakhshan to make study tours to northern Pakistan to observe its primary health care sys-tem (see Table 2). The effectiveness of this cross-border initiative, and its broader potential for global health care delivery, has not to date received adequate attention in the medical literature.

The purpose of this study was to assess the acceptability of the cross-border health approach to clients, providers and ministry of-

MethodsThe structure and activities of the focus group discussions (FGDs), including study design, staff selection and training, participant selection, question guide development, and data collection and analysis, were developed following standard guidelines (7). Focus group participants were selected using criteria to allow for diversity

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affection for the project and appreciate the initiative. The Tajik professionals working in Afghanistan are very professional and their attitude towards patients is admirable. The son or daughter of a local commander can afford to go to Kabul or Karachi but for the majority of the population, Khorog [capital of Gorno-Badakhshan] Hospital is the best option.

Tajik professionals appreciate the cross-border initiative both for professional and personal reasons. Professionally, Tajik doctors are

of remuneration, and service in Afghanistan supplements their income. In addition, they believe that exposure to Afghan medical cases enhances their clinical knowledge and skills. One Tajik health professional explained, there are hardly any growth opportunities for Tajik professionals in Tajikistan, and another commented, I want to enhance my clinical skills by treating or diagnosing a disease that does not exist in Tajikistan. Tajik professionals recognize that the Afghan health system is quite weak, that there

On a personal level, Tajik health professionals are committed to serving Afghans due to strong cultural, religious, and ethnic bonds. A Tajik doctor stated, I believe that the cross-border project is an excellent initiative. It has provided us with an opportunity to do something good for the poor people of Badakhshan Afghanistan. Life has always been hard in Afghanistan and I came here to assist our own people. Another stated, there is no difference between Afghan and Tajikistan Badakhshan. We are all the same people. We have relatives in Afghanistan Badakhshan. However, their quality of life is very poor. We will always support our Afghan brothers and sisters.

Afghan and Tajik community leaders and professionals reported that the cross-border initiative strengthened relations between communities living on both sides of the border. The head of the Tajik border police stated, because of this project, the 72 year old relationship will strengthen. A Tajik health professional explained that, The cross-border initiative has united us even more and we are now able to meet our relatives on a regular basis. The head of a District Hospital in Gorno-Badakhshan commented, the cross-border health project is a positive initiative between the

Number of Tajik health professionals employed in Afghanistan Badakhshan border districts

22 34 32

Tajikistan, into Afghanistan border districts surgeries 311 surgeries, including

12 surgeries during emergency visits emergency visits

3 6 12

for treatment in Tajikistan, but who were not allowed to cross the border

7 (7 died) 11 (11 died) 27 (5 died)

border study tours0 45 44

in ethnicity, age, gender, geography (from both sides of the border), and professional backgrounds. The question guide for use in FGDs was designed to capture data about the knowledge, perceptions and experience of Tajik and Afghan health professionals, community leaders, patients and their family members about the cross-border health program. Sessions were conducted in the local languages, recorded on audio-tape, transcribed verbatim, translated into

analyzed. A grounded analysis (8) was carried out independently by three members of the research team. The analysis sought to identify viewpoints that were expressed by the majority of each group, as well as views raised by a smaller number of voices that also suggested recurrent observations and concerns.

Twenty-one FGDs were held with a total 194 participants (median 9 participants) during October and November 2011; 42.8 % of the participants were female and 57.2% were male. (See Table 3 for a

Table 4 outlines the key themes, suggestions, and recommendations offered by the FDGs.

The Afghan FGDs reported that Gorno-Badakhshan is the most cost-effective, feasible, and geographically accessible location for accessing health care services. As one Tajik health professional commented, we are just a stones throw away. The cost of travelling to Faizabad, Mazar-e-Sharif and Kabul (towns in Afghanistan with comparable health care facilities) are exorbitant, according to the discussants, and nearly impossible to reach during winter. An Afghan community leader explained, the cross-border health project is a very cost effective option as most of our people are poor and they cant afford to go to either Faizabad or Kabul.

In addition, Afghan patients reported a strong preference to seek medical services in Tajikistan, as they perceive the quality of care to be better than what is offered in Afghanistan. Patients who have experienced health care either in Afghanistan from Tajik professionals or in Tajikistan itself respect the Tajik professionals. An Afghan community leader commented, I personally feel

12

Afghanistan

2 (17) 2 (22)

in Afghanistan0

Afghans who have tried to access health care in Tajikistan 4 (37) 0

Tajiks who have dealt with Afghans who tried to cross the border to access health in Tajikistan

0 2 (17)

Community Leaders 4 (36) 2 (20)

Pakistan 1 (8) 1 (8)

Tajik health professionals who have shared Shared culture with Afghans in region

Salaries are too low in Tajikistan

Afghan health professionals who have

in Afghanistan

Shared culture with Tajiks in the regionMaternal and child health indicators have improved, especially because of the Tajik female health professionals

Acceptability of female health professionals

Badakhshan

Afghans who have tried to access health care in Tajikistan

Border procedures are unclear and need improvement, including transparency

many Afghans

The border should be kept open 24 hours per day to allow for transfer of emergency cases

Tajiks who have dealt with Afghans who tried to cross the border to access health in Tajikistan

should be introduced Formal agreement should be signed by the two governments

health team should be established

Community leaders Shared culture between Tajiks and Afghans

Tajikistan and Badakhshan Afghanistan

should be considered and very poor

Formal agreement should be signed between the two governments

Strict measures should be taken to interdict drug smuggling at the border Tajik and Afghan health professionals should be provided with more training

Tajik and Afghan health professionals

Pakistan electronic and manual monitoring systemsand health policies should be organized prior to the trip

end of the tripPakistan health professionals should be provided with opportunity to see the health systems in Afghanistan and Tajikistan

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two Badakhshans. This project is changing our mindset. We have started understanding each other. This has increased the level of acceptance and respect for each other. We are learning many new things.

Afghan and Tajik professionals described the exchange of knowledge and exposure as a result of the program. Afghan health professionals claim they have learned about infection control and hygiene from the Tajik professionals. Tajik doctors have appreciated and learned from various aspects of the Afghan health system as well. An Afghan vaccinator working at a CHC commented that we feel good when [the Tajik professionals] appreciate our work. For example, they appreciate our Essential Programme for Immunization (EPI) registration system, vaccination cards, etc. They told us that such a system does not exist in Tajikistan. We are now very motivated due to their encouragement and support.

Participants in the FGDs explained how health indicators, especially maternal and child health outcomes, improved as a result of the cross-border initiative. An Afghan community leader claimed that earlier, many women died during labor. Since the Tajik obstetrician and midwives have been deployed at our local health centre, maternal mortality has reduced. Many safe deliveries are happening at our clinic.

In addition to improving health status, professionals involved in the program have recorded other positive development effects, particularly around gender norms. A male Afghan health professional noted that due to Tajik female health professionals consistent presence and positive impact, the local community has started accepting female health professionals. Community behavior is changing day by day. Flexibility is replacing rigidity and that is one of the most important development indicators. A female community leader in Tajikistan explained this positive effect when she stated, Afghan women will meet our Tajik health professionals, and their understanding about gender equity, equality, and womens rights will improve. More girls will be encouraged to go to the medical, nursing, and midwifery schools to pursue their career in health. As a result, Badakhshan will have more female health professionals.

Still, the cross-border initiative does not operate without its

border-crossing restrictions, many Afghan patients attempting to cross the Tajik border for treatment have often waited for several hours or several days to cross, and at times even a month or more. Patients can die when not permitted to cross (see Table 2) or while they wait. A disheartened father of a 16 year old girl from a small rural village related his experience: I tried to take my daughter to Khorog, but the Tajik border authorities would not allow her to cross. My only option was to take her to Faizabad,

arrived in Ishkashim, her condition started deteriorating. She was immediately taken to the health centre, where she died.

Though an agreement between the two Badakhshan Governors

not aware of the agreement or do not yet recognize it. To ease the border restrictions, interview participants suggested that a comprehensive agreement be signed by a range of national authorities (e.g., health, interior, immigration) in both countries.

and standardize the type of documentation required to cross the border and create measures that allow attendants to travel with patients, especially mothers with young children. Afghan and Tajik health professionals suggested that the working relationship between health professionals on both sides of the border be strengthened to achieve these goals. To resolve the problem of drug

suggested that governments should target such illegal activity and execute prevention measures more vigorously.

health professionals agree that outdated equipment or lack of

demand for care. At facilities in Afghanistan, there is often a shortage of pharmaceuticals and supplies, and limited bed space. Short consultation periods of only 3-5 days for Tajik doctors who visit Afghanistan are inadequate to meet the demand for health care services across the border.

On the other hand, the time that Tajik health specialists spend in Afghanistan delays health service delivery at their home health care institutions in Tajikistan. Some Tajik professionals also expressed concern that infectious diseases could cross the border due to inadequate disease management systems in health facilities in Afghanistan. The health professionals interviewed suggested that priority next steps to enhance quality of care would include equipping Tajik health facilities with updated equipment, quality instruments and supplies, enhancing diagnostic and treatment facilities in Gorno-Badakhshan, increasing the number of beds in facilities, and controlling infectious diseases with separate quarters. A Tajik health professional also recommended a joint cross-border transportation system to facilitate transfer to health facilities.

In response to the steady brain drain of Tajik health Some

of our doctors leave the country and go to Moscow. If a good quality referral health facility was established in the sub-region, most of our medical specialists would return. Most Tajik and Afghan health professionals and community leaders argued that that there was a dire need for a health facility referral center or hub to serve the populations on both sides of the border, and all expressed willingness to pay for (some of) the costs associated with transportation, diagnosis, and treatment. They opined that the proposed facility could enable residents to avoid the exorbitant costs of travel to Dushanbe, Faizabad, Kabul, or Moscow for diagnosis and treatment.

According to the participants in the FGDs, enhancing facilities is one way to retain and satisfy the health professionals involved in the cross-border initiative. Tajik professionals also requested improved transportation and accommodations during their visits to Afghanistan. Both Afghan and Tajik health professionals expressed a desire for additional clinical enhancement and training. Both also asked to have the opportunity to visit renowned health facilities elsewhere in the region to enhance their clinical skills further.

Health professionals who had travelled to northern Pakistan were very appreciative of the opportunity to see another health system. All agreed that this experience allowed them to learn different approaches in emergency and inpatient care, and to

14

acquire information on electronic and manual health management information systems. Participants asked that comprehensive orientation sessions on planned activities and briefs describing health centers and systems be offered prior to future visits. They

post-visit information sharing. Afghan and Tajik health professionals and community leaders

expressed concern that the cross-border initiative may only be

costs, including transport. To provide greater access to health programs, particularly in emergency situations and for the poor, participants proposed implementing a community-based health

management system.

The FGDs provided insights of the current cross-border health program based on community and health professionals views.

motives of those participating in the cross-border health program. The FGDs suggest that Afghan and Tajik health professionals increasingly perceive cross-border healthcare interactions as an opportunity to achieve their professional ambitions and to meet their responsibilities to members of their community residing in the border regions. At the same time, Afghan patients are looking to Tajik health professionals to satisfy their heath care needs. Rather than travelling to towns in Afghanistan, Afghan patients are seeking care from Tajik professionals working in the Afghan health system or to Tajik health professionals making short-term visits to Afghan Badakhshan. Afghan patients also seek easier access to health care in Tajikistan to address some of their critical needs.

Tajik health professionals are willing to work across the Tajik-Afghan border to secure additional compensation but also to gain experience in diagnosing and treating diseases that are rare in Tajikistan and to provide care to communities sharing their religion, culture and history.

which in many cases go beyond health carethe discussions also recommended a number of concrete actions to improve the current process. For example, the participants emphasized the importance

that would allow all community members in the cross-border area to access care. It should be noted that this component was not in fact included in the original design of the proposed cross-border program, but participants of the FGDs strongly suggested that this component should be added to it.

To further justify the value of the cross-border approach and to

a systematic study of the direct and indirect costs of accessing cross-border health care is needed. In addition, a separate study is needed in order to measure the enhanced capabilities of the staff who have been actually involved in the existing program.

One major challenge is that of overcoming the lack of trust at the level of the central governments, mainly related to cross-border

and developing an effective cross-border health policy and

improve crossing by Tajik health professionals and Afghan patients could greatly increase the chances for success, and have not been

participants in this study include simplifying the border crossing procedures, setting up transparent costing and pricing at a level

for all interventions, and adequate communication of the potential

Cross-border health programs are not easy to implement.

in Europehave shown that regulated movement of health professionals and patients is possible (9, 10). Such movement can improve health care by making use of different capabilities of health care services across different countries.

A cross-border health program offers the potential to maximize resources in both Afghanistan

and Tajikistan. Such a program can contribute to rapid progress in health improvements than more conventional (intra-national)

an apparently positive outcome on health-seeking behaviours, and improvements in the role of women in health service provision and

the general acceptability of the approach by health professionals, community leaders, patients and their family members, and offer a number of concrete recommendations for measures to enhance the impact of such a program.

oeva and Alibek Alibekov for their help in conducting the FGDs and assistance with data collection,

their contributions in planning and performing this study, Diana Marques for producing the map, and Nazneen Kanji for comments on an earlier draft of the paper.

1. Islamic Republic of Afghanistan, Ministry of Public Health.

Health, 2005.2. Balabanova D, McKee M, Pomerleau J, Rose R, Haerpfer C. Health service

3.

4. The Republic of Tajikistan.

5.

border health care. pmed.1000005.

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6.

7. Dawson S, Manderson L. A Manual for the Use of Focus Groups. Boston,

8.

Accessed July 18, 2013. 10.

Policies, 2011.

16

Ahmad Shah Salehi, MD, MSc1Abdullah Fahim, MD1Caroline Fitzwarryne, BNurs, MA2

1

2

t the emergence of an equitable, democratic, and peaceful country is one way to move towards reducing corruption. Hand in hand with this is the need for nation-building activities through the development and improvement of institutions, infrastructure, and services. The follow-on from any successful military intervention will be inef-fective if corruption prevents sustainable development. Reducing corruption in key institutions is thus an urgent priority in any such setting.

State, Hillary Clinton, said: We have agreed that we need a differ-ent kind of long-term economic partnership, one built on Afghan

out reform, and providing good governance. According to mu-tual accountability as much as 20 percent of the aid could ultimately depend on Af-

it was up to each donor whether to make its aid contingent on such reforms and that the benchmarks could vary from country to country (1).

-

to address and limit corruption. In 2008, the Independent Admin-istrative Reform and Civil Service Commission (IARCSC), to-

Accountability and Transparency Project, commissioned consul-

tants to work with key Afghan agencies to develop a Corruption Monitoring System in Afghanistan. A paper on this was developed in July 2008 by Hawken and Munck (2) and a consultation work-shop was held in Kabul in August of that year to discuss the pro-posal, with a report produced to advise on future action (3). The workshop developed 14 indicators, seven relating to anti-corrup-tion reforms and actions, and seven relating to conceptions, toler-ance, perceptions, and experience with corruption. The report built on a number of 2006 baselines, especially relating to legislation,

-ment Bank, World Bank, Intervention Fund for Agricultural De-

agreed that all indicators needed to be monitored regularly. It was also agreed that regular surveys of public servants and the public would be required to monitor tolerance, perceptions, recognition, and experience. There would also need to be new data whereby random Ministries were regularly monitored relating to service fees and complaint mechanisms. A working group was established in 2008 to drive this process forward.

Within the Ministry of Public Health (MoPH) it was agreed that Indicator 4 (Transparency, Accountability and Corruption of Pub-lic Servants) and Indicator 7 (Public Interfacerelating to service fees and complaint mechanisms) would be assisted by the initia-tives being developed in the Ministry relating to the high-level

both of which are discussed below. In 2008, the MoPH selected three strategies to reduce corruption, and these are described in its

The Go -

and Transparency Project commissioned consultants to work with Afghan agencies to develop a Corruption Monitoring System. A subsequent workshop and report identifying indicators served as the basis for several strategies proposed by the Ministry of

sub-optimal. Proposed reasons range from tribal pressures to maintain the status quo at the level of government, to a preferential focus of donors on discrete health programs over institutional development. However, if sustainable services are to be provided by the Government in the long term, the Ministry cannot be circumvented and efforts need to be directed to strengthening public institutions. The urgency of this task has been highlighted by international donors at the Tokyo Conference in July 2012, stating that pledges will be conditional on the government implementing measures to combat corruption and bolster democracy. Two initiatives

Transparency Working Group which has the approval of the Executive Board but cannot begin without funding. This paper calls for

in the MoPH programs poised for implementation. Keywords: Transparency, integrity, corruption, health, Afghanistan

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2008-2013 Health and Nutrition Sector Strategy (4). The aim was to develop the MoPH into one of the top performers among Af-ghan governmental bodies through the introduction of the highest professional standards for transparency and integrity.

The three strategic innovations in the Strategy were to: 1. Establish a permanent high level group within the MoPH to

set standards and monitor procedures which can be subject to corruption. The group would assist with remedial action and report to the Minister so as to ensure that procedures were transparent. It would be called the Transparency Working Group (TWG);

2. areas where there were expected to be more opportunity for individuals to operate corrupt practices (this would be a short-term initiative to identify priority areas); and

3. Establish a free-access feedback mechanism on the MoPHs -

ernment but not reporting to the MoPH) to address com-

The Strategy was supplemented by three additional initiatives. These were to:

4. Develop a permanent Dispute Resolution Commission as required in the 2008 Civil Employees Law;

5. Reinforce implementation of human resource practices ac-cording to the Civil Employees Law and procedures;

6. Agree on anti-corruption principles through the annual high-level meeting retreat of key stakeholders and senior

the plans undertaken by the MoPH to implement them, and discusses the re-sults, including barriers to implementation. Recommendations are made regarding suitable mechanisms to drive the anti-corruption agenda forward.

The terms of reference and establishment of the TWG were agreed upon by the MoPH Executive Board, chaired by the Deputy Min-ister for Administration, with membership of all Director Generals

since late 2009 because of lack of appointments in key ministerial positions since the election.

The TWG is to be a permanent forum to monitor processes, share experiences, investigate system failures, produce common analyses, and make recommendations to the Executive Board re-lating to professional standards and strengthening ministerial in-tegrity and transparency (5). The three strategic areas of focus are:

Detection: developing internal complaint mechanisms and monitoring system operations.Prevention: improving institutions and systems, including administrative rules and procedures; also, awareness-rais-

Prosecution and sanctions: investigating cases, and admin-istering disciplinary measures and punishment.

monitored regularly, and on which recommendations of remedial action will be based:

1. Recommendations to the Minister following complaints to the Civil Service Commission (CSC) Appeals Board, Na-tional Assembly (Parliament) Committees for Health and Complaints, and from external audits when they occur.

2. outcomes of those investigations.

3. Program implementation according to required procedures.4. Payment processing and settlement according to required

procedures.5. Procurement management according to required proce-

dures.6. Development, vetting and monitoring of contracts for work

for the MoPH.7. Asset management according to required procedures.8. Complaints lodged with the MoPH Dispute Settlement

established) and outcomes.9. Recruitment processes and signing of Code of Conduct ac-

cording to procedures.10. Appraisals and disciplinary action relating to non-perfor-

mance according to procedures.11. Selection for training processes based on objective criteria.12. -

tive criteria.13. Professional Registration and Accreditation processes ac-

cording to international or national standards, whichever is most appropriate.

-

that a positive approach of assessing priorities for management process improvement with target areas would be more effective than looking for corrupt practices and individuals. It was also agreed that mentoring of staff in implementation of remedial ac-tion was crucial, rather than providing reports and walking away. Follow-up and feedback on an ongoing basis would be essential.

An initial assessment in the three Construction Departments be-ing restructured in 2009 was undertaken. A number of agreements

-al action. The approved actions were:

Finalizing the structure and job descriptions drafted during Pay and Grading.Better coordinating among Construction Planning Depart-ment [Technical (Engineering) and Financial], Construc-tion Monitoring Department, and Construction Procure-ment Department.Following procurement standards.Basing technical assessments on international standards.Tightening of management processes including computeri-zation, operational plans, action sheets, program budgeting and reporting.

of funds and additional human resources for implementation. Oth-

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18

support further action could not be taken.

-pendent of the MoPH (it would report to the President), and an establishment and implementation plan, were agreed upon by the MoPH Technical Advisory Group in 2009 (7). The agreed man-

It will be a fully autonomous unit (not part of the MoPHs management structure, and thus free from interference or

health care service clients or health service providers off the record, impartially provide advice, and mediation if required, on ways to resolve issues, and recommend changes to the MoPH or private health systems and procedures, so problems do not reoccur. It will provide an annual report to the Executive Board, and to the National Assembly (Parliament) Grievances and Complaints Committee and the Health, Safety and Sport Committee.

three Afghan representatives from the World Health Organization (WHO), Integrity Watch Afghanistan and the Afghanistan Human Rights Commission (who have each nominated a representative). A Presidential Decree will be sought for its establishment when a

has yet committed to funding the HCO. When funding is available, there will then be a considerable education campaign for staff and health service clients.

A new Civil Employees Law was enacted in mid 2008. This law includes a requirement that each Ministry establishes a Dispute Resolution Commission (DRC) to resolve issues relating to the following matters: unfair disciplinary measures; illegal orders of supervisors; not being allowed access to personal records (which is now a requirement in international personnel law; unjust or dis-criminatory treatment by a superior or colleague; or a violation by a manager or supervisor.

It was required that the chair of the Commission be a Director General within the Ministry, someone who has a background in mediation. A proposal for this was developed within the MoPH, including nomination of three internal Commissioners (one of which had a human resources (HR) background including me-diation) and a proposed mode of operation for the MoPH DRC. The Executive Board agreed in principle and the proposal was forwarded to the CSC. Funds have not been made available for implementation, so it has not yet been established.

Through the development of the HR Policy 2008-2013, HR Strategy and Plan 2008-2010 (5), and Workforce Plan 2009-2013 (8), the MoPH has documented the HR procedures required by the 2008 Civil Employees Law, and the innovations required for

There are some key innovations required to reduce corrupt practices. Despite Pay and Grading being completed in late 2009, inequitable salaries and allowances are still being paid to external

organization employees (who receive more) compared to civil servants. Equitable salary arrangements need to be implemented along the lines argued in the Workforce Plan. Applications for jobs

identifying most of these, however establishment of professional councils to register and accredit professionals will reduce this

gradually reduce in number. A midwifery accreditation board has been established, and a nursing accreditation board is being developed. Some initial work is underway in planning for a Medical Council. These initiatives should be fast-tracked.

Building Plan 2009 (6). Training of workers for the MoPH often focuses on the health professionals; it is essential to train and

and procurement, project management, property management, and other key administrative tasks. Action on this is slow, again due to donor monetary priorities which focus on grassroots health service delivery, not institutional development.

At the Results Conference and Retreat (2010) the ten top actions to reduce corruption were presented and are listed below. These were generally agreed principles as listed in international anti-corruption literature.

Action 1: Politicians and senior executives must lead in the anti-corruption drive, not be part of the problem. Laws are

examinations. If politicians/senior executives do not know the laws then they must be educated about them. People at the top are observed either upholding the laws or breaking the laws. If senior people are seen to be breaking the laws, junior staff might do the same.Action 2: Provide awards or incentives for those who run transparent services, and recognize those people publicly. There are some excellent managers who have eradicated corrupt practices in their areas and are operating transparently according to the law. They are very stressed from repeated pressure to revert to systems based on bribes and personal favors.Action 3: Provide equitable operational budgets. Many areas of MoPH have no operating budget (they have a salaries budget, but no funds for provision of goods and services or purchasing of equipment). If a basic budget was provided many areas would not need to obtain underhand funds.Action 4: Focus on the positive, not the negative. Most people want to do the right thing. Do not search for corruption. Offer to assist managers in high-risk areas to improve their management practices so operations are more transparent. If you are seen as helping, and not a threat, people will respond, and you will have a win-win situation.Action 5: Regarding recruitment issues, obey the Civil Employees Law. If an issue cannot be resolved in the MoPH according to the law, refer it to the CSC for resolution. Regarding disputes with supervisors, or unfair treatment of employees, establish the DRC (as required in each ministry under Civil Employees Law)

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Salehi et al.

and resolve such matters through this mechanism.Action 6: Establish a HCO, and have this body deal with concerns about delivery of health services. People are often scared to come

service is the only way for fair resolution.Action 7: Implement regular meetings of the TWG. Provide adequate funding for the Secretariat as working with each area to assist development of standards and monitor implementation

be used to enforce changes where required, or to recommend congratulatory awards by the Executive Board.Action 8: Provide funding for good managers to work as assessors and mentors, assisting managers of at-risk areas to: assess management processes, decide on necessary remedial action to implement transparent processes, and monitor improved processes regularly.Action 9: Rotate staff, so that staff do not have to work for very long in areas known to have huge pressures to accept bribes or provide personal favors. It is very hard to resist pressures over a long period of time, and it is important to move vulnerable people to areas of safety, so corrupt practices do not get ingrained in certain areas. Action 10: Encourage a culture of honesty and trust. Much of the gossip about individuals circulating in the Ministry is not true. Encourage staff not to spread rumours, but only to rely on reliable evidence. If a person criticizes another to you, and as manager you need to investigate, ask the complainant to provide

taking action against a subordinate or colleague, or criticizing a superior. The issues were noted but no executive action was taken to

implement them rigorously.

CommentsWhile the Government of Afghanistan has expressed a commitment

to be lack of political will in donors, government, and the MoPH

Within the MoPH, and the Government as a whole, there are unwritten political and tribal pressures to maintain the status quo, including a reluctance to transition long-standing incumbents from key positions. Changing the system of bribes and personal favors will be uncomfortable for some, as people try to avoid discomfort.

The focus of donors has been on grassroots activities to improve health status, not to implement institutional development activities. While funding is sometimes provided for health service delivery at a level which cannot be spent within the year, there are well-planned proposals for long-term initiatives to reduce corruption that do not

or donors. Institutional development has not been considered a priority, perhaps because it is not as appealing to the public in donor countries as is, for example, improving the Millennium Development Goals. And yet the health status indicators will not improve as much as they could if the systems are not working to employ and train the right people, monitor the quality of their

performance, ensure that funds are used appropriately and that procedures are followed effectively.

Donors have chosen, in many cases, to establish management systems outside the Ministry for many programs they support, so

sustainable services are to be provided by the Government in the long term, the Ministry cannot be circumvented and efforts need to be directed to strengthen public institutions. The urgency of this task has been highlighted by international donors at the Tokyo Conference in July 2012, stating that pledges will be conditional on the government implementing measures to combat corruption and bolster democracy.

It is, therefore, essential to commit the monetary funds and human resources to implement innovations that reduce corruption, with key priorities being the six listed and described in this paper. Two unfunded initiatives, the HCO and the TWG, have had no tangible support and must be funded urgently. Monitoring of success will be the task of the TWG. The planning for this includes details of

Human resources are a key priority to drive change. If this is not done promptly, much of the best Afghan talent may leave the civil service, reducing sustainability of services. We need to retain the best people within government, and prevent the brain drain to non-governmental organization contractors and international organizations.

Through its detailed documentation, the MoPH has charted the course for the future. This paper calls for the government and international community to go beyond verbal commitments

programs poised for implementation. Only by doing so will

greater transparency and integrity.

Given that this article was submitted in late 2011, some of the recommendations may have already been implemented by the MoPH. Nonetheless, many challenges exist that need further assessment and measures to address.

1. Moh

July 18, 2013.2.

3. (IARCSC), and UNDP Accountability and Transparency Project. Report of

UNDP, August 3 2008.4.

20

5.

6. Islamic Republic of Afghanistan, Ministry of Public Health. Needs

7. Islamic Republic of Afghanistan, Ministry of Public Health, Unpublished

8.

Accessed 2010.Fitzwarryne C. Syria Feasibility Study for Aleppo and Homs Cancer

10. Islamic Republic of Afghanistan, Ministry of Public Health. Detailed 16

Public Health, August 2010. Accessed November 2010.

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Khalil Ahmad Mohmand, MD, MBA, MPH11

Ahad Bahram, MD, MBA1

1

Tobacco smoking is the second leading risk factor (after blood pressure) for the global disease burden. Disease attributable to tobacco smoking, including secondhand smoke, caused 6.3 million deaths and account for 6.3% of global Disability Adjusted

or secondhand tobacco smokingthe involuntary inhalation of smoke from tobacco productscan cause the same problems as direct smoking, including disease, disability, and increased mortality (2).

Although the Ministry of Public Health (MoPH) of Afghanistan considers smoking as one of the countrys key emerging public health problems (3), no data is available in the literature about the prevalence of cigarette smoking and socio-demographic predictors at the population level in Afghanistan. Likewise, the MoPH established a bylaw for the ban of cigarettes and tobacco use in governmental and public places, but no evidence exists on the enforcement of such a bylaw in Afghanistan. Hence, there is need for reliable prevalence data on cigarette smoking and its sociodemographic predictors that can inform evidence-based policymaking on smoking-related issues.

The study objectives are: a) to estimate the prevalence of cigarette smoking among the male population, aged 15 years and older, in Kabul city, and b) to assess knowledge, attitudes and practices in regards to cigarette smoking. Moreover, it is anticipated that this study will help in designing methodologies for future research and studies on smoking at the national level in the country.

MethodsThe researchers used a population-based cross-sectional study design. The target population of the study was men aged 15 years and older who live in Kabul. The sample size for the study was

50% estimated proportion, a design effect of 1.3, and 5% desired precision were considered (4, 5).

A probability proportionate to size (PPS) cluster sampling was used to sample the target population. According to 20082009 data from the Central Statistics Organization (CSO), Afghanistan, Kabul has a population of 2,831,400, living in 17 districts (6). Each district is divided into guzar or neighborhoods. We considered each neighborhood as a cluster and listed it in the sampling frame.

from a sampling frame of 370 clusters. In the second stage, ten households were randomly selected from each cluster. Thus, the

was the household. In each household, one eligible person (male aged 15 years or older) was interviewed.

The questionnaire, based in part on the WHO-STEPS instrument for survey on chronic disease risk factor surveillance (7), was

questionnaire was widely administered.To measure the reliability of the questionnaire, a reliability

analysis using SPSS software was carried out. The analysis

Introductionconducted on the nature and magnitude of cigarette smoking in Afghanistan. The objective of this study was to assess the prevalence of cigarette smoking in the male population in Kabul, Afghanistan. Methods -istan, in September and October of 2010. In total, 554 randomly selected men aged 15 years and older were interviewed.Results -sive of all respondents, 85.4% (35.2% active smokers and 50.2% passive smokers) reported exposure to cigarette smoke. Respon-dents were more likely to smoke when they grew up in a family where family members smoked (adjusted OR, 2.2; 95% CI, 1.53.4) or reported having friends who smoked (adjusted OR, 7.08; 95% CI, 3.514.2). Among non-smoking respondents, 78.3% reported that they were exposed to secondhand smoke (35.6% at home, 56% on public transportation).Conclusion. Smoking prevention programs in Afghanistan should target early adolescence and consider the role of family and

-rettes through increasing excise tax. Given the high prevalence of exposure to secondhand smoke, developing and enforcing policies to ban cigarette smoking at work and in public places are also a priority.Keywords: Afghanistan, cross-sectional study, smoking, prevalence, tobacco use

22

value (5, 8). The questionnaire included sociodemographic questions, questions on family and friends smoking history, and questions on the respondents smoking history and current smoking behavior. The survey teams obtained informed consent before administering the questionnaire. The questionnaire was administered by surveyors to respondents in person.

The data was entered and analyzed with SPSS version 18.0. In order to ensure the validity and reliability of the data, double data entry was carried out independently by two research assistants. Preliminary data cleaning included running frequency counts of key variables to identify any outliers and implausible values. Next, data were coded in preparation for data analyses.

Results were expressed as frequencies, percentages, median, and mean. Logistic regression was used to assess the relationship of multiple independent variables and smoking as the dependent

the model chi-square and improvement chi-square was obtained. A

for factors independently predicting cigarette smoking. The ORs were adjusted for literacy, income level, age, and marital status.

We obtained ethical and technical approval from the Institutional Review Board (IRB) of Afghanistans MoPH.

Participant characteristics are summarized in Table 1. A total of 554 individuals participated in the survey. The mean age of respondents was 31.3 (SD=13.37) years, mode 18 years, with minimum and maximum reported ages of 15 and 65 years, respectively. Among participants, 57.8% (n=318) were married and 42.2% (n=233) were single. Among the respondents, 79% (n=437) were able to read and write, while 21% (n=117) could not read or write. The average household income was reported with a median level of 12,000 AFs (Mode=10,000AFs), with minimum and maximum income of 1000 AFs and 150,000 AFs, respectively (see Table 1).

During the study, 35.2% (n=195) (95% CI, 31.239.2) of

smoking at least one cigarette per day, on average. Altogether, 85.4% of respondents (35.2% active smokers and 50.2% passive smokers) reported some level of daily exposure to cigarette smoke.

Among respondents, 98.6% (n=341) of non-smokers and 99.5% (n=191) of smokers anticipated risks of some type of health problems as a result of smoking. The vast majority of the respondents, 96.2% (n=531) had received information regarding adverse effects of smoking from different sources, including

other sources.Among those who had received information, 86.5% (n=460)

information. The majority of respondents (88.8%, n=490) named

smoking; 50.8% (n=281) reported radio as the best media tool for conveying this message.

Table 2 summarizes the adjusted OR for smokers and non-smokers. Among smokers, 25.8% (n=50) reported that at least one family member smoked in the family where they grew up, while 94.2% (n=178) of smokers reported that their close friends smoked. Those respondents who grew up in a family where family

Family members smoke 2.2 1.53.4

Friends smoke 7.1 3.514.2

Other substance use 2.5 1.73.8

status

Age 32.2 (11.0) 30.8 (14.5)

Single

Married

Tajik

Pashton

Hazara

Others

Literate

Illiterate

Primary

Secondary

High school

University

Other

Income 10,000AFs

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members smoked were more likely (adjusted OR, 2.2; 95% CI, 1.53.4) to smoke than those respondents whose family members did not smoke. Those respondents whose close friends smoked were more likely (adjusted OR, 7.1; 95% CI, 3.514.2) to smoke compared to those respondents whose friends did not smoke. Literacy, age, income level, marital status, and ethnicity were not

Study participants were also asked about their use of other substances. Twenty percent (n=111) of participants reported using naswar (a type of tobacco used sublingually), 4% (n=22) reported using Charas (the same drug as hashish), and 0.4% (n=2) reported consuming alcohol. In addition, 1% (n=6) of respondents reported using hookah (a water pipe for smoking). Smokers were slightly more likely (adjusted OR, 2.5; 95% CI, 1.73.8) to use other substances than non-smokers (see Table 2).

Characteristics of respondents who smoked are listed in Table 3. Among smokers, 15% (n=28) reported that they had started smoking cigarettes at the age of less than 16 years old, while only 1% (n=2) started smoking after the age of 30 years. Fifty percent

of smokers (n=98) reported smoking 11 to 20 cigarettes per day, and 18% reported smoking more than 20 cigarettes per day.

The average individual expense for cigarettes was reported to be 565.6 49.2 AFs per month, with a median level of 450 AFs, minimum and maximum levels of 60 AFs and 1900 AFs, respectively.

Among smokers, 48.7% (n=95) reported that they started smoking because their friends had smoked, while 8.7% (n=17) reported that they started because their family members were smokers. Only 49% (n=96) of smokers reported that they smoked outdoors; the remainder smoked both indoors and outdoors.

The majority of smokers (92.3%, n=180) reported that they were advised to quit smoking; 76% (n=136) of smokers were told to quit by family, while 13% (n=24) were advised by friends (see Table 3). Among the non-smoking study participants, 17.3% (n=48) were former smokers. Before quitting, they had smoked for one to thirty years. Among those who had quit, 64.6% (n=31) quit due to health problems, 18.8% (n=9) due to familys advice, 2% (n=1) as a result of advice from friends, while only 14.6%

Exposure to secondhand smoke was reported by 78.3% (n=281) of non-smoking participants of the study. Exposure occurred in public transport (56.1%), homes (35%), market place (16%),

schools (2.9%).

to estimate the burden of cigarette smoking among men aged 15 years and older in Kabul city. The prevalence of smoking among men aged 15 years and older is estimated to be 35.2%. This is alarming, since one out of every three men (15+ years) in Kabul is a smoker.

This study shows that the initiation of smoking began at a very early age, where 15% of smokers started to smoke before the age of 15 years, and 57% of smokers started to smoke between 16 and 20 years of age. Studies show that legislation restricting cigarette purchases by children would limit minors access to tobacco products (9, 10). However, no age-restriction policy to regulate cigarette purchase by children exists in Afghanistan at the current time.

Long duration of smoking affects life expectancy and mortality. A study looking at mortality and life expectancy in relation to long-term cigarette smoking found that both the number of cigarettes smoked and duration of smoking are strongly associated with mortality risk and the number of life-years lost (11). Our study results show that 50% of smokers smoked 11 to 20 cigarettes per day.

There are no previous data on cigarette smoking prevalence available that might be used to conduct a trend analysis or comparison within Afghanistan. However, the results of this study can be compared to data from neighboring countries. The prevalence of cigarette smoking among men aged 15 and older in Pakistan is reportedly 36% (12), which is similar to that of Kabul. The prevalence of smoking among men aged 15 years and

15 28

1620 yrs 57

2130 yrs 28 54

1 2

32 62

50

18 35

60 113

35 66

>1000 AFs 4 8

My close friends smoked

Some family members smoked 17

Other reasons 43 83

Outdoor

Both indoor & outdoor 51

Family 76 136

Friends 13 24

4 8

Health personnel 2 3

Schools 2 3

Others 3 6

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older in the Islamic Republic of Iran is documented as 23.4% (13), which is lower than the prevalence in Kabul. The rates in other neighboring countries are reported to be 52.9% in China (14), and 28.5% in India (15).

smoking is an important predictor of smoking among participants. The likelihood of becoming a smoker is higher among men who grew up in a family where at least one member of the family smoked. Parents and/or other family members can be negative role models for children in the family. The relationship between parents smoking habits and childrens smoking habits is documented in other countries as well. A study conducted in Malaysia found that children whose fathers were smokers were almost twice as likely to smoke when compared to those whose fathers were non

same study also found that, within families, sibling smoking habits

and peers was an even larger predictor of smoking than smoking

especially during childhood and adolescent development. Adolescents look to their friends and peers as role models. Our

theory (SCT) constructs. One SCT construct is observational learning, which occurs when a person watches the actions of another person and observes the reinforcement that the person receives following those actions. The process of observational learning accounts for why people in the same family often have common behavioral patterns. Some children observe their parent when they smoke and some children observe other children and peers smoking. If the smokers experience reinforcement that the observers consider rewarding, the observers are more likely to imitate that behavior (18).

Secondhand smoke or passive smoking is another alarming phenomenon in Kabul. Daily exposure to secondhand smoke can cause or exacerbate a wide range of adverse health effects, including lower respiratory infections in children younger than 5 years, ischemic heart disease in adults, asthma in adults and children, and lung cancer in adults (19). The evidence shows that even brief (minutes to hours) passive smoking has an effect on the cardiovascular system that is, on average, 80% to 90% as large as effects from chronic active smoking (20).

Our study found that 78.3% of non-smokers are exposed to smoke in their everyday environment, such as in public

existing bylaw banning cigarettes and tobacco use in governmental and public places. Meanwhile 35.6% of non-smokers reported being exposed to smoking at home, which not only causes health risks associated with secondhand smoke, but is also a negative

indoor smokingreported by 51% of smokersis another factor that increases exposure to secondhand smoking for non-smokers, we recommend and support the design and implementation of more e