How can aid funds best be spent in areas of high instability? This scoping study from the British Department for International Development (DFID) argues that development funds would have the most impact on improving health outcomes in the Helmand Province of Afghanistan, a country where health is consistently ranked among the top 5 priorities of the general public. The study shows how whilst insecurity is hampering health service delivery in some places in the province some of the time, there is a sound health development framework in place. What is needed is to support equitable, quality service delivery and systems development, and at the same time incrementally work on building state capacity and governance. The authors argue that raising state visibility and legitimacy in the health sector is currently not advisable, except at provincial hospital/directorate level. At district level and below, the public sector health services have been contracted out to an NGO, which is working to the principles of neutrality and impartiality.
The authors highlight how the country is now at a critical period and an important way forward in health and other sectors is to focus more on the ‘how’ of capacity development rather than so much on the ‘what’ in Helmand. Sound information is scarce, but currently it is likely that because of the insecurity deaths and illnesses are more of a problem in Helmand than national averages suggest. The authors also argue that making better use of, or building upon, existing DFID initiatives in other sectors e.g. infrastructure, advisory, sub-national reform and oversight of service delivery could be useful, but not in isolation of addressing the top priority: implementation of health service delivery and the systems crucial for achieving good results. Finally, it is recommended that for the foreseeable future there should hardly be any more health facilities built, inappropriate medical equipment and supplies must not be allowed to be donated/provided and projects or ad hoc activities that do not fall within the framework of Afghan government policies, guidelines and systems must not be allowed to happen. Much of the support in health needs to be targeted to address equity, to better enable effective, efficient and quality health services to be delivered to those hard to reach in the province. In this way the support would also contribute to stabilisation.
