After decades of conflict, the provision of healthcare in Afghanistan leaves a lot to be desired. The Afghan Government now sees this as a priority area which if improved could help turn the population away from the Taliban insurgency:
It is letting the population have the basic human services that they need and showing them that the government is supporting them and is providing those services,” explained Captain Samantha Toop, from the Royal Army Medical Corps, who is currently Medical Liaison Officer in the Helmand Provincial Reconstruction Team (PRT).
It also needs to be impartial, and that’s why we don’t stop the Taliban using the facilities,” she continued.
It is not something the Taliban can take a message from saying, ‘oh look they are picking and choosing sides and who is getting what’.
And it helps boost people’s opinions of what the government is doing. They realise that they are being catered for and they are being looked after and by sticking with the government they will get what they are entitled to.
Maternal mortality is a particular priority area. In Afghanistan, 24,000 women die in childbirth each year, due largely to early marriages and frequent pregnancies, as well as the lack of healthcare services.
The Afghan Ministry of Public Health wants to provide more midwives and female doctors as part of its drive to improve services across Helmand and the Helmand PRT is aiding this effort through their health team.
Capt Toop explained that maternal mortality and prenatal health quickly became a special interest of hers:
Initially I was the first female on the health team so I took that on as one of my main focuses because the biggest problem in health is maternal mortality,” she said.
A lot of our projects are pushing to improve that side of things. Their healthcare system only came into play in 2005, so it is quite junior,” she added.
In fact in 2004 an estimated one quarter of the population had no access to healthcare. In 2003, there were just 11 doctors and 18 nurses per 100,000 population.
According to the World Health Organization that number had almost doubled by 2010. Health services are now contracted to the Bangladeshi organisation BRAC Afghanistan.
Although in Helmand services still cover quite a range; from a husband and wife team trained in very basic healthcare and based in a village of around 500 to a regional clinic for 15,000 people and finally to district hospitals such as that in Bost in Lashkar Gah.
Recently a major pre-service midwifery education initiative was launched by the Ministry of Public Health to train and graduate new midwives:
There is only one female doctor across the whole of Helmand province,” said Capt Toop.
I think there are roughly 36 midwives but there should be 70 odd. So there is a big shortage. But the ones that are employed are in the district hospitals where they are able to do more complex births such as caesareans.
In addition to having the staff available to deal with deliveries, Capt Toop explained that one of the biggest barriers to improving the survival rates of pregnant women is the lack of awareness amongst women that they need to go to a clinic.
She explained that about 90 per cent of women give birth at home, traditionally helped by a ‘birth attendants’. But such birth attendants are often religious figures usually with no medical training.
Across the country just 14 per cent of births are attended by a skilled health professional, according to the United Nations Population Fund:
These unqualified attendants are not able to recognise the dangers, so women are dying from postpartum haemorrhage where they’re just bleeding too much. They aren’t able to have transfusion services at home so they die,” explained Capt Toop.
A lot of the women are too young, anaemic, fragile boned - they are just not able to cope with the complications of birth.
It is not the lack of clinics, the clinics are now there - it is just trying to get them and their husbands to say, ‘look there is something seriously wrong, get to a clinic, they can deal with it’.
The complex gender roles in Afghanistan contribute to the problem:
There are still lots who would say it would be better to die than have a man treat me,” Capt Toop explained.
So until we get the female staff things will be held back, but I don’t think that is something the PRT can solve. It is just going to take time to educate the men.
One way of getting the message across to men about the importance of maternal healthcare has been through the use of traditional shuras, or village meetings.
Capt Toop explained that in Musa Qal’ah health teams from the PRT have spoken at such shuras and taken a message from the District Governor that maternal healthcare is important, not only for the woman as an individual, but for the family as a whole:
The people go from these shuras and tell others the message, so by Chinese whispers it becomes more acceptable to take women in labour to a clinic,” Capt Toop said.
The main role of Capt Toop and the PRT health team in all this is to make sure that all the health agencies are working together and to an agreed aim. Capt Toop acts as the interface between the Military Stabilisation Support Teams (MSSTs) and the PRT:
So it is making sure that out on the ground, the stabilisation advisor or the district team, whether that is any of the military actors, governance or anything, follow the Helmand plan in the health sector.
I go out and visit the district centres and find out how they are getting on and whether they need any advice on any health projects.
For example in Lashkar Gah we have a number of provincial projects that are being developed so it is just making sure that those are continuing steadily and there is a plan in place on how they are going to be used.
They are not just going to be a big shell that is going to get abandoned after a while.
One issue she is having to rein in is the desire that some people in the PRT teams, such as the MSSTs and Female Engagement Teams, have to intervene directly:
I have to say let them get on, give the Afghan people advice and help build their capacity - ultimately it must come from the Afghans.
However, she said that they can help in other ways. For example, by recommending improvements such as a security wall for a clinic compound or a separate entrance for women.
One of the recent achievements that Capt Toop is particularly proud of is the provision of three new ambulances.
These new vehicles, supplied and funded by the PRT, will be used to transfer women experiencing complications in labour from regional clinics to the main provincial maternity hospital in Lashkar Gah:
This is about setting up a scheme where they can call an ambulance and get emergency support.
It is about making sure there is a good referral process so when a clinic can’t manage or when it is too technical, a caesarean for example, we can then take them to hospital and offer that service rather than relying on a hired car.
Capt Toop explained that she goes out once or twice a month to each different district to make sure every new ISAF stabilisation team that comes through understands what the goals in health provision are:
I make sure they understand that we are capacity-building rather than getting directly involved in medical care - making sure that the district health officer, the Afghan guy, is actually linking into the line ministry and has good communication, that health education is working well, the clinics are functioning.
So apart from being a good thing for the Afghans, what benefit does all this bring ISAF in Afghanistan?
Improving healthcare is quite crucial, even though quite a lot of people forget about it,” she said.
It is a massively good thing for counter-insurgency. It’s winning over the population.
This article is taken from the November 2011 edition of Defence Focus - the magazine for everyone in Defence.