Over the past 20 years, health has been one of the key areas of international assistance to Afghanistan. From 1980 onward most of the health services were delivered through cross border operations and targeted at dealing with emergency situations. In this context, non-governmental organisations (NGOs) have been given considerable operational freedom on the ground, negotiating directly with local commanders and developing their own networks which grew separately from the local, weak or absent Ministry of Public Health (MOPH). Under the Taliban regime, NGOs acted as a main interface with the Taliban and the international community.

Following the 11^th September events and due to the influx of donor resources, the number of NGOs has significantly increased and so has the size of their operations. To date international and national organisations dominate the health service provision, with more than 80% of the health system being managed by NGOs.

The MOPH faces the challenge of organising health service delivery in a manner that provides adequate coverage and quality of health care to the population against a background of limited resources and highly fragmented health services delivery. While significant effort is being invested by the central government in defining a basic package of services, most observers of present day Afghanistan would agree that it will take a considerable time to build up the implementation capacity of the central and local governments.

• The presence of the State and MOPH is reinforced: The mission highlighted the critical role of functioning health facilities in creating a sense of routine and progress for national and local authorities.

• Access to basic health care is ensured:. Despite the enormous logistical constraints posed by the Afghan terrain, recent health interventions and the increase in the proportion of clinics and hospitals supported by NGOs are impressive. The existing network of clinics and hospitals is a key element giving local populations a sense of confidence that there are infrastructures and resources in place to deliver health services and to rebuilt trust in them.

• MOPH and national staff are provided with economic means: Obviously, working for NGOs provide health professionals with an economic outlet not available to them otherwise. By enabling MOPH staff to access a monthly living wage through incentives, NGOs create also an environment conducive to normal daily activities.

• Skills are improved: In general the projects created a supportive environment whereby health staff are given the opportunity to upgrade skills through training, supervision and follow-up.

3. ALONGSIDE THE PROJECT CYCLE

Following the events of September 11, this phase has been challenged by pressures to rapidly expand the population coverage and for quick and visible impact. New health interventions have not always been grounded in initial assessments of real needs. Competition to first "fly agency flags" prevailed and anecdotal evidence suggests that this approach disrupted previous NGO assistance in given areas.

In the urgency to respond, participation of beneficiaries has been negligible and this raises the question of whether projects have been modelled according to aid packages or to the social dynamics of the communities. In many instances, activities were initiated with limited understanding of the coping strategies and demands of populations.

Those agencies which did not scale up their own capacity allowed for time and preparation of new projects and were able to identify needs and to ensure some level of community participation.

Assessment and analysis for the range of acute natural disasters that characterises Afghanistan such as earthquakes and floods had been given limited priority, except for large-scale NGOs with expertise on emergency preparedness.

Over the last months, the fact that, in Afghanistan, health needs are many and overwhelming makes prioritisation extremely difficult. The NGOs adopted two main strategies to reach and work with populations: setting up health interventions in and around urban centres and covering remote and under-served areas. Efforts to rationalise the distribution of resources have been successful in areas where the MOPH had enforced meaningful co-ordination to direct NGOs to those areas identified as the most in need. Nonetheless NGO support remains physically scattered and structure-based with a focus on individual health facilities.

At the project-design phase, constraints in relation to increasing budgets and geographical area were often under-estimated. The tendency has been to scale-up health service delivery operations and to become involved in new sectors, such as nutrition. In many instances, scaling-up affected organisational NGO capacity and may undermine the quality of interventions.

With few exceptions, relief assistance is the main strategy for delivering health care. Much is being said in relation to integrating PHC elements, even though the concept refers to a stable situation where there is a perspective for development. However, in practice, the population is not defined, neither geographically, nor by registration and the health district as the basic organisational unit is virtually non-existent. On the contrary, the health service delivery is dominated by curative health posts, mobile teams and feeding centres, operating independently.

As a matter of fact, many field situations are somewhere in-between, -non-development, non-emergency-, which makes it difficult to determine strategic aspects, such as exit strategies and the role of different actors. Ad hoc decisions are sometimes shaping health projects, with implementation being far from straightforward and more a matter of "muddling through" than of planned rational intervention.

- Utilisation of services: Users who present to health services are far from representative of the general population. Target populations such as women and children are not always seen as the main beneficiaries and preventive services remain under-utilised. In discussions with health staff and communities, a number of barriers to utilisation are summarised below:

• distance and time to the clinic
• lack of transport
• poor quality of physical examination
• limited understanding of how modern allopathic health care works
• cultural barriers and reluctance to travel far from home

It is apparent that simply developing services is insufficient to address the current imbalance. Yet initiatives which are strengthening linkages between communities and health centres are limited and will probably require significant time to develop.

Quality of care: There is evidence that sub-standard medical practice is widespread, including excessive, multiple and inappropriate prescriptions and short duration of the clinical encounter with reporting consultation times of 5 minutes or less. This can be explained in part by the high demand on mobile clinics and OPD departments which makes it difficult to provide high quality of care. In addition, anecdotal evidence indicate that Afghans over-rely on self-prescribed medication and intravenous infusions and self-refer late to health facilities. Modern health care treatment is equated with the administration of drugs: the larger the quantity, the greatest the variety and the more direct the treatment route, the better.

Overall it is found that insufficient attention is given to the quality of diagnosis and treatment. The perceived need for rapid curative treatment has resulted in uncontrolled demand for antibiotics, injections and intravenous infusions. The irrational use of drugs and its implication on drug resistance remains problematic and unadressed. Commercial interest encourages private practitioners, and even health professionals to respond to these demands.

- Access to human resources: Working in a complex setting such as Afghanistan is seen as extremely demanding and requires an uncommon range of abilities. However, most NGOs face difficulties in recruiting expatriate staff, especially in the medical and co-ordination field. In addition, short-term commitment and high rate of staff turn over creates obstacles to lessons transfer and learning and institutional memory.

Managers are often over-stretched by their responsibilities and the absence of leadership at the field level creates a fragmented work lacking coherence, efficacy and a clear strategic vision. Competition among NGOs and other international agencies has also a deterrent effect on national qualified staff who are in heavy demand, especially well-qualified female health professionals.

The unequal position of women within health care remains a critical issue as well as the professional status of MOPH health workers whose salaries are below subsistence level. Deregulation in relation to incentives prevails and there is an unbalanced distribution of available health workers, the majority being concentrated in big cities.

Co-ordination: Most agencies have established a working relationship with MoH counterparts and local authorities. At provincial level, sectoral co-ordination through formal mechanisms such as regular meetings is well-functioning although extremely time-consuming and placing extra strain on aid workers. While meetings provide mainly for an exchange of information, effective co-ordination seems difficult, each NGO working to implement its own models. The major challenges obviously remain moving beyond the rhetoric of collaboration on to planning how to implement it so that it results in the sharing of objectives, resources and expertise.