Whenever the topic of sustainability in Afghan health projects is raised, the initial thought that comes to mind is financial sustainability.We usually forget that besides financial sustainability, there are other factors that are as important as finance, if not more.
First, human resources for health is the backbone of the system. Afghanistan faces a chronic shortage of professional and auxiliary health workforce. This shortage is strongly inequitable in favor of large cities. As an example, you will hardly find 1 physician for 20,000 rural residence of Bamyan or Badakhshan. While, in Kabul city, there are 1 for 1,800 people. Gender imbalance adds to the complexity. There is not a single female physician in the entire rural areas of Bamyan, except a few in the central hospital. A few years ago, a female physician from Tajikistan was employed in a comprehensive health center in Bamyan, and she became famous as the only female provider in the entire rural areas of Bamyan. In addition, human resources for health include health administrators and managers. Running a clinic requires management and administrative skills.
Second, community participation in health services is vital for success, efficiency, and sustainability of the entire heath system. Health is not about disease control, it is about the potential of individuals to be productive and happy. It is long known that the health of the population is less influenced by medical care than the living condition of the community. Community participation in health care means provision of clean drinking water and proper sanitation. Community participation means increased knowledge of the community members on health behavior, healthy eating practices, and healthy environmental initiatives. Community participation means ownership of the health clinic, monitoring and evaluation of health services, and even financing health initiatives. Without involvement of communities in their own health, it is impossible for clinics or hospitals to produce healthy communities.
Third, an effective governance and management system. Privatization of health services is a major policy challenge. Business-oriented hospitals are after money rather than health of the public. I believe in participation of communities in taking control of their health, but not in allowing huge profit-making business to be made out of medial services. You cannot put a price health. In a free unregulated market of medical services, like in Kabul-style, millions of dollars of Afghan households are spent without really improving the quality of life of the Afghans. In addition, Afghans are no stranger to the widespread corruption in every office and industry.
The good news is that these factors can be a beginning of the solution to the problem of long-term sustainability. An increased number of human resources for health can bring down the cost of services, making it sustainable.
The NGOs top-down interventions have made sponger out of Afghans, who have developed a habit of waiting for the NGO to build them a latrine or water well. Making communities accountable, allowing them to monitor and evaluate the services, and even starting to contribute financially is the way to make the system sustainable.
Finally, a proper management system at the capital and provincial level will take advantage of the 1.1 billion dollars spent annually out of pocket of Afghan household to build a sustainable health system.
I am not saying that we should not take advantage of the international funding. That is part of the developed nations commitment to developing countries, and Afghanistan must be grateful for it. But ending international donations to health projects must never be the reason for reduced or lack of health services.