Health sector development in Afghanistan: the way forward.OVERVIEW
Health sector development is a critical component of nation-building and a cornerstone of any exit strategy for US and coalition forces in Afghanistan. The current fragmented organizational structure of military health care assets is not conducive to comprehensive development efforts. (1) Centralized planning and direction are essential to unity of effort and a necessary ingredient to the coordination of health sector development in Afghanistan. An organizational structure is needed that enables leaders with vision to vector military health sector strategy development. The direction must be aligned with the Afghan National Development Strategy, civilian organizations, and coalition partners operating throughout the theatre. As a lesson for future nation-building operations and reinforcement of the concepts outlined in this paper, Jones et al (2) observed that successful health sector development efforts must include effective planning, coordination, and leadership. The price of failure to act can be quantified not only in fiscal and material terms, but in human tragedy as well.
Health sector development in Afghanistan is foundational for the future viability of the government of Afghanistan and the health and welfare of its people. (2) In fact, as stated by the US Joint Forces Command, "a viable health sector is vital to a nation's well-being." (3(p7)) Statistics from UNICEF, presented in the Table, show nearly zero improvement in under-5 mortality and infant mortality rates, among other significant public health measures. (4) Unfortunately, health sector development in Afghanistan is suffering from a lack of centralized planning and direction. While numerous military professionals of all backgrounds and affiliations are doing a great deal of things to try to help the people, government, and country of Afghanistan, there is a tremendous lack of unity of effort within the military structure in the arena of health sector development. The way ahead will require significant change, including a reorganization of healthcare services in theatre, dynamic leadership, and the development of an achievable and coordinated strategic plan that will generate unity of effort.
Organizational structure serves as an enabling backbone. In Afghanistan, the organization of healthcare services is fractured, particularly as it pertains to health sector development, resulting in a dysfunctional execution of strategy. The Afghan health system has 3 major components: the Ministry of Public Health (MoPH) for the civilian sector, the Ministry of Defense (MoD) for the Afghan National Army, and the Ministry of the Interior (MoI) for the Afghan National Police, among other security services. All of these components contribute to the national health of Afghanistan.
The healthcare assets of coalition forces in Afghanistan also have a number of major components (Figure 1). One element of the US Forces-Afghanistan is a staff medical planner who has recently arrived on scene. The International Security Assistance Forces (ISAF) staff headquarters has primary responsibility for strategic guidance regarding reconstruction and development. The ISAF mission consists of 41 nations. There are 28 provincial reconstruction teams (PRTs) located across Afghanistan, task organized under maneuver tasks forces within regional commands with a mission to help develop and aid in governance and development. To complicate the organizational structure, the PRTs are situated across 5 regional commands, each with a different lead nation. To complicate the organizational structure, the PRTs are located in 5 regional commands, each with a different lead nation. The Combined Security Transition Command-Afghanistan (CSTC-A), whose efforts are directed at the Afghan National Army and National Police, is responsible for embedded training teams and police mentor teams. The Combined Joint Special Operations Task Force-Afghanistan, with its unique mission, provides direct patient care of an episodic nature in high value geographic locations. In the near future, a medical command will be added to the fray. Finally, there are a number of task force maneuver units which arrive and operate with their own medical assets under the control of a line commander. The end product of this conglomeration is a command and control system which has little unity of effort toward health sector development.
There are 11 units with medical assets located at Bagram Air Base alone. Each of those medical resources is organic to a combat arms unit and are dedicated solely to that specific unit. Consequently, those medical assets are at risk of being underutilized in their medical specialties (depending on the operations tempo) and unavailable to provide support to other medical functions without prior coordination and authorization. While each unit brings skills, expertise, and workload capacity to Bagram Air Base, there is little coordination of effort on the installation. As is the case in many locations and in many organizations across Afghanistan, there are superb medics in the task forces that are doing great things in isolation. However, because there is very little unity of effort, these advances are often unsustainable. This is the end result of an absence of an enabling strategy for comprehensive health sector development.
Further complicating the organizational structure of health services in Afghanistan are the existence of numerous civilian organizations. The United Nations Assistance Mission in Afghanistan is a coordinating body to which a US military liaison officer is assigned. The European Commission works with multiple nongovernmental organizations (NGOs), including the International Medical Corps, Aide Medicale International, Health Net International, Medical Refresher Course Afghanistan, among others. The US Agency for International Development (USAID) also works with numerous NGOs including Bactar Development Network, Norwegian Afghan Corps, Sanayee Development Organization, Afghan Development Association, Adventist Development and Relief Agency, among others. (5) Many of these organizations have designated geographic responsibilities and all are heavily involved in health sector development efforts.
Figure 1. The command organization of coalition forces with healthcare assets in Afghanistan. (5) Glossary ISAF: International Security Assistance Forces USFOR-A: US Forces-Afghanistan RC: Regional Command CJTF: Combined Joint Task Force CSTC-A: Combined Security Transition Command-Afghanistan CJSOTF-A: Combined Joint Special Operations Task Force-Afghanistan TF: Task Force
Military units and civilian agencies, along with Afghan organizations, contribute to health sector development. At times, the missions of these organizations intersect, however, their efforts are often uncoordinated. In fact, a stove-piped structure of funding and leadership has evolved which limits vision and inhibits cooperation. There is a published commander's intent which enables decentralized execution, but there is little or no centralized planning or control as advocated in joint doctrine. (6(pIV-16)) The fractured structure dates back several years and is likely an evolutionary result of funds allocation in the area of responsibility. In practice there is little, if any, interagency coordination.
The funding environment in Afghanistan is extremely complex. A number of "colors of money" exist including:
* Commander's Emergency Response Program funds which are earmarked for urgent humanitarian relief and reconstruction.
* Afghanistan Security Forces Funds, often referred to as Title 22, which are provided through CSTCA for training and sustaining Afghanistan National Security Forces.
* Title X funds for active duty personnel and operations, Field Order Officer funds used for US Forces only and generally available for expenses less than $10,000.
* Overseas Humanitarian Disaster and Civic Assistance funds sponsored by the US State Department.
In addition, organizations such as USAID, the European Commission, and numerous NGOs, as well as the MoPH, have their own funding sources, rules, and regulations. Given all these "colors of money," there are funds available for comprehensive health sector development and capacity building missions, but the complexity required in this system encourages thinking within the confines of the funding stream. In addition, each type of funding comes with its own administrative rules and reviews. (7)
What has evolved is a system of decentralized planning and execution among the many uncoordinated agencies and units in Afghanistan. Essentially, many civilian agencies and military units are moving forward in their respective lanes as they understand and interpret their role within the Afghan National Development Strategy (ANDS) construct, and the strategic and operational environment. The consequence of this uncoordinated approach is isolated progress which is unsustainable over the long-term. This unsustainable progress will potentially undermine the credibility of the coalition and the government of Afghanistan in terms of health sector development. However, the coordination and combined efforts of healthcare resources in Afghanistan could have a positive tangible and sustained impact on the country's healthcare infrastructure.
Within the framework of the ANDS, a new and comprehensive strategic direction is necessary for the future of health sector development in Afghanistan. While US and coalition forces provide superior and well-coordinated care to wounded Warriors, the humanitarian support and infrastructure development missions are shrouded in fog and friction, not caused by the war, but products of the organizational structure and bureaucracy that has developed over time. The way forward lies in improving the capacity and capability of the Afghan health system through training and skills development of healthcare professionals and support staff, as well as through bricks and mortar. While training and capacity building are integrated into some existing strategy, including that of Combined Joint Task Force-101 (CJTF-101), execution is more problematic.
As one example, the International Medical Mentorship and Training Program (IMMTP) is designed to improve the human capacity of Afghan physicians across the country and is synergistic with a 2-week program targeted at Afghan nurses and ancillary medical staff. The program applies to all the major healthcare entities in Afghanistan, including MoPH, MoD, and MoI, and is a cooperative effort among the US, Korean, and Egyptian hospitals on Bagram Air Base. Unfortunately, the funding mechanisms in place are not structured to support such a program, as it crosses funding streams. Despite a nominal cost and support by the commanding general, CJTF-101, funding remains elusive. As a consequence, instead of receiving training 6 days a week over 90 days in 3 coalition hospitals, the first 5 physicians in the program traveled to and from Bagram Air Base from outlying areas 2 days a week over the 90-day period. The second class started in February 2009, with subsequent cohorts of students entering training every 6 weeks. However, attendance of cohorts in the future is at serious risk if funding issues are not resolved. Currently, the commitment of the Afghan government is illustrated by the agreement of the MoPH, MoD and MoI to fund the salaries of their students for the duration of the program. After 5 years of failed attempts at starting such a program, the IMMTP has begun and has taken a major step forward in building relationships and capacity within the Afghan health system. As stated by the US Joint Forces Command,
Sustainable projects that restore and build [host nation] capacity, especially in public health systems, achieve longer and wider spread results than limited scope direct patient care projects. Capacity building also garners positive good will and political capital without creating misplaced dependency and does not undermine [host nation] legitimacy to govern. (3(p10))
The US is currently in jeopardy of losing one great opportunity.
There are a number of viable solutions to the strategic quandary that exists for health sector development in Afghanistan. First, a number of medical challenges must be understood, including the irregular environment, the health and security relationship, and the accomplishment of a health sector assessment that enables the development of a strategy that leads to a "culturally appropriate health sector capacity that garners long-term positive effects for the commander." (3(p3)) The Afghan National Development Strategy should serve as a guide for such efforts for both military affiliated and civilian resources in country. The fifth pillar of the ANDS, health and nutrition, is based upon the basic package of health services (BPHS) and the essential package of hospital services (EPHS), which are foundational in meeting the healthcare needs of the people of Afghanistan over the long-term.
The statement from Joint Publication 1,
Attaining unity of effort through unity of command may not be politically feasible given the sometimes divergent missions of all the involved organizations, but it should be a goal (6(pxix))
is directly applicable to the coalition. The command and control network for military health sector development should be reorganized, including a plan for integration that links the major players in the area of responsibility and creates a central vision. According to the Doctrine for the Armed Forces of the United States,
Integration is achieved through joint operation planning and the skilled assimilation of forces, capabilities, and systems to enable their employment in a single, cohesive operation rather than a set of separate operations. (6(pIV-17))
Leadership will be critical to this end, including those of appropriate rank and ability to execute such a monumental task. A funding system that can accommodate the uniqueness and needs of the environment will be essential to the development and support of any strategic initiative. In addition, the establishment and measurement of important objectives, based upon public health goals as advocated in the BPHS and EPHS, are essential. The adoption of long-term public health measures, such as infant mortality and malnutrition, will force a paradigm shift in how business is normally conducted. Finally, perspective of time has to adjust from one focused on short-term goals tied to annual personnel evaluations and deployment rotations (6 to 12 months) to one focused on real substantive change in 5 to 10 years. The US and its coalition partners cannot afford to continue to fight one year wars, particular as that fight pertains to health sector development.
... the joint medical community must expand its interagency and multinational relationships; joint force commanders should seek innovative ways to employ medical capabilities to help achieve security and stability; ... (3(p3))
Beyond the joint force, it is imperative that the efforts of the joint and combined force be aligned with the multitude of NGOs and aid agencies operating in Afghanistan to potentiate and sustain the effects. Three specific recommendations include:
1. Dedicate resources specifically for health sector development and clearly align the health sector development mission under one joint medical command and control element (JMC2E). *
A. Obtain a funding source dedicated entirely to health sector development.
B. Funding is appropriated to the JMC2E for execution.
The medical command that is currently in the process of deploying to Afghanistan has the potential to be a significant factor in the unity of command through the provision of a centralized planning framework. More importantly, the medical command structure should be modified to become a JMC2E function. The primary mission of US military medical units is to provide care to US service members. The probability of making real, timely, sustained progress would rise dramatically if the health sector development function was
* established as a separate and important mission,
* recognized as an essential element of any exit strategy, and
* specifically allocated to the JMC2E which was then given the appropriate resources to execute that mission.
A proposed organizational structure is presented in Figure 2. As it currently stands, health sector development is a secondary mission for most units operating in theatre. The empowerment of the JMC2E must include planning responsibility for all military medical assets in theatre, including those of CSTC-A, CJTF, and the Combined Joint Special Operations Task Force, ensuring unity of effort. Any healthcare lead in Afghanistan must be joint in structure and operation. Establishing the JMC2E Surgeon as the US Forces-Afghanistan Surgeon is a beginning. However, providing the element with the necessary resources, including funds earmarked for health sector development, would give the element both the authority and the responsibility to execute its mission.
If health sector development truly is important, significant resources must be dedicated to it. In the short term, this can be accomplished by adding more personnel with public health training to incoming medical units such as the medical command. In the long-run, success will require changes to current philosophy and changes to organizational structure to complete health sector development missions.
Funding mechanisms must be established that do not involve an inordinate approval process that impacts the timeliness of execution of health sector initiatives. A congressional mandate through the Department of Defense may be required to establish the authority to fund health sector development directly and eliminate competition with other developmental initiatives.
2. Ensure the right people (leaders) are in the right places with the right training and credentials. Strong and visionary leaders will be critical to changing course and aligning medical resources in-country. Leaders for health sector development, at the JMC2E and in supporting units, must, at a minimum, have public health education, background, and/or experience and rank appropriate for the authority, responsibility, and importance the function holds. As shown in Figure 2, the staff responsible for health sector development planning need to have an appropriate mixture of administrative experience critical to planning and process, clinical experience necessary for medical development, and mobility enough to engage in relationship building and sustaining those relationships across Afghanistan. It is unknown at this time if the JMC2E will have this capability; however the element must be supported through joint action by the military and other US and international agencies (Air Force, Navy, Army, Public Health, US Agency for International Development, European Commission, United Nations Assistance Mission in Afghanistan, etc) to provide the manpower needed to expand its mission of health sector development.
Presently, medical leaders are expected to have experience in health sector development. The military would be better positioned if training were modeled in homogeneous currency based platforms across all services to develop the critical skills needed to contribute to health sector development, similar to the Air Force's "Flight Path" methodology for personnel development. (8) This approach would be particularly effective if the health sector development mission is incorporated into each unit. Coordination of efforts should not be expected but required, thus optimizing unity of effort. If health sector development is not made a priority for military units, the combination of low priority, a lack of training, few available resources, and leadership that is not dedicated to the mission will lead to failure.
3. Develop a long-term strategy for military medical assets that establishes clear objectives and aligns resources toward accomplishing Afghan National Development Strategy objectives. The strategy should follow ANDS goals and be coordinated with all medical agencies in Afghanistan, including USAID, the European Commission, and associated NGOs.
Partnerships with other military and civilian organizations are essential for successful health interventions during stability operations. (3) The JMC2E would be responsible for nurturing relationships with other agencies in Afghanistan and coordinating efforts across organizations to amplify the effect of health sector development efforts and initiatives. Given that the US military will be in Afghanistan for an extended period of time, the JMC2E is really a solution of 2 to 3 years in duration. A more robust organization, designed around the concepts and principles described in this paper, will have to be established to support an enduring effort to develop the Afghan medical infrastructure. Moreover, a sustainable economic model with an entrepreneurship bent is a critical part of the strategic direction needed to ensure the fiscal viability of the health care system. Afghan medical providers need economic security and incentives to keep them from seeking opportunities in the United States or abroad.
Figure 2. The proposed joint medical command and control element organization and structure for Afghanistan. [ILLUSTRATION OMITTED] Liaison Officer Cells It is preferable that each LNO come from their respective organization, ie, USAID LNO is an USAID employee; otherwise the US military may provide an LNO. Facilitate health sector development information and relationships. Provide military commanders information and resources to implement the MoPH health sector development strategy. Coordinate all military health sector development with civilian and government agency efforts. Training Cell Provide military units with Afghanistan appropriate plans and programs to achieve specific ANDS goals. Ensure that all military medical assets understand Afghan National Development Strategy. Ensure all military medical assets are empowered to accomplish health sector development. Promote training of all types for women. Public Health Cell Create and promote training programs for medical professional development, medical administration, quality assurance, medical equipment maintenance and medical facility maintenance. Circulate within Afghanistan providing expertise, guidance and support to any military assets involved in medical training programs. Promote military commander awareness of personnel training programs. Plans, Programs, and Operations Cell Coordinate all health sector plans with MoPH, civilian, governmental and individual military units. Ensure health sector development is synchronized with all other security and development efforts. Develop and publish nation-wide, long-term health sector development plans. Finance Manage all health sector development funding. Assist in all aspects of acquiring funding for health sector development projects. Establish long-term funding solutions. Promote stability of the Afghan medical community by developing economic incentives. Facilitate relationships with World Bank, EU, and other international donors.
The time for action is now. Military participation in health sector development is critical to nation building efforts and any exit strategy. Lives, limbs, and livelihoods of US Soldiers, Marines Sailors, and Airmen, as well as those of our coalition partners and the Afghan people hang in the balance.
The authors acknowledge the particular contributions to the content and message of this article by the following colleagues who were also serving and, in some cases, continue to serve in Afghanistan:
CPT Kristy Linginfelter, SP, USAR, Surgeon/Physician Assistant, 426th Civil Affairs Battalion
Lt Col Garry Feld, MSC, USAF, Deputy Commander of Administration, Joint Task Force MED
Col Douglas Anderson, MSC, USAF, Lead Mentor, CSTC-A Afghan National Police
CDR Evelyn Quattrone, NC, USN, Officer in Charge, Cooperative Medical Assist Team
MAJ Maureen Nolen, AN, USA, Task Force MED J-5, Plans and Programs
Lt Col Tamara Averett-Brauer, NC, USAF, Chief Nurse, Task Force MED
We thank all of you for your insight, service, and diligence in working to leave Afghanistan better than you found it.
(1.) Thompson DF. The role of medical diplomacy in stabilizing Afghanistan. Def Horiz. May 2008;63.
(2.) Jones SG, Hilborne LH, Anthony CR, et al. Securing Health: Lessons from Nation-Building Missions. Santa Monica, CA: RAND Corporation; 2006. Available at: http://www.rand.org/pubs/monographs/2006/RAND_MG321.pdf.
(3.) Emerging Challenges in Medical Stability Operations White Paper. Norfolk, VA: US Joint Forces Command; October 4, 2007.
(4.) Afghanistan information page. United Nations Children's Fund web site. Available at: http://www.unicef.org/infobycountry/afghanistan_statistics.html.
(5.) Whitescarver HL, Hale TE. Presentation at Combined Joint Task Force Surgeon's Health Sector Development Conference; December 17, 2008; Bagram Air Base, Afghanistan.
(6.) Joint Publication 1: Doctrine for the Armed Forces of the United States. Washington, DC: Joint Staff, US Dept of Defense; March 20, 2009 [ch 1]. Available at: http://www.dtic.mil/doctrine/jel/new_pubs/jp1.pdf.
(7.) CJTF-101 Chief of Staff Memorandum: Fiscal Year 2008 Resource Management Policy and Procedures. July 1, 2008.
(8.) Roudebush JG. Medical readiness. Presentation to the Military Personnel Subcommittee, Committee on Armed Services, US House of Representatives, Statement of Air Force Surgeon General, Lt Gen James G. Roudebush; 8 May 2008; Washington, DC. Available at: http://www.sg.af.mil/shared/media/document/AFD-070427-005.pdf.
Maj Paul Brezinski, MSC, USAF
Lt Col Montserrat Edie-Korleski, MSC, USAF
CPT Timur S. Durrani, MC, USAR
Col Douglas Howard, NC, USAF
COL Michael Manansala, AN, USA
* The concept of a "medical command and control element" was originated by LTC Mark McGrail, then the CJTF-101 Surgeon.
When this article was written, the coauthors were assigned as follows:
Maj Brezinski was Plans and Programs Officer (J-5), Task Force MED, Bagram Air Base, Afghanistan (Sept 2008-Jan 2009).
Lt Col Edie-Korleski was Plans and Programs Officer (J5), Task Force MED, Bagram Air Base, Afghanistan (Jan 2009-July 2009).
CPT Durrani was the Senior Public Health Analyst, CJTF-101, CJ-9, Bagram Air Base, Afghanistan.
Col Howard was the Deputy Commander, Craig Joint Theatre Hospital, Bagram Air Base, Afghanistan.
COL Manansala was the Deputy Commander, CJTF-101, Task Force MED, Bagram Air Base, Afghanistan.
Comparative child survival and birth statistics for Afghanistan showing essentially no improvement in a 17-year span. Source: United Nations Children's Fund (4) Children under age 5 mortality rate (per 1,000 live births) Calendar Year 1990 260 2007 257 Infant (under 1 year) mortality rate (per 1,000 live births) 1990 168 2007 165 Crude birth rate (number of births per 1,000 population) 1970 52 1990 52 2007 48