Interview with Dr. Mubarakshah Mubarak

In this article, LMG/Afghanistan Project Director Dr. Mubarakshah Mubarak talks about the reconstruction of the health system in Afghanistan from 2002 to 2012, and the importance of leadership, management and governance in ensuring the success of that process.

Meeting in Waras District, Afghanistan

Dr. Mubarakshah Mubarak has a long and storied history of working in the health sector in Afghanistan. He is currently Project Director for the USAID-funded LMG project in Afghanistan, implemented by a consortium led by MSH. From 2006 to 2012, he was Project Director of the recently completed Tech-Serve Project which provided capacity building to the health sector in Afghanistan. From 2003 to 2006, Dr. Mubarak served as the Program Manager for capacity building support at the central level of the Afghanistan Ministry of Public Health for the USAID-funded REACH project. From 2001-2003, Dr. Mubarak saw the fall of the Taliban in 2001 and the start of the reconstruction of the Afghan health system in 2002 while working in the country as a national Expanded Program on Immunization (EPI) officer for the World Health Organization (WHO). From 1994 to 2000, Dr. Mubarak supported the MOPH and NGOs in the implementation of maternal and child survival package introduced in Afghanistan by UNICEF. Prior to 1994, Dr. Mubarak was deputy training advisor for Afghanistan for the Cross Border project, implemented by MSH and funded by USAID.

MSH (Alain Joyal): Dr. Mubarak, the results achieved by the health sector in Afghanistan over the past 10 plus years are nothing short of spectacular. The situation in 2001 and 2002 was dire. The health system was in shambles—devastated by years of war and neglect. Access to primary care was below 10% and immunization rates had fallen below 20% throughout the country.

Medicines and medical supplies were scarce and the quality was often unreliable. There were essentially no female health workers actively working in most of the country, and nine out of 10 women were on their own for labor and delivery, with no trained birth attendant. Not surprisingly, maternal, child, and infant mortality were among the highest in the world. What were the key factors in turning this dire situation around?

Dr. Mubarak: At the fall of the Taliban regime, the leadership at the very top level of the Ministry of Public Health had disappeared. Under the new Islamic Republic of Afghanistan established in early 2002, the Afghan public health officers who remained in the country during the years of conflict and those who returned all worked closely together, and with the representatives and experts from the international community to address the numerous challenges.

International experience for health system reform in post conflict situations and experts’ views were absolutely critical in the process of health system reconstruction in Afghanistan. After over twenty-five years of civil war in our country, and the effects of the war on development, Afghan health officers were not having all of the knowledge, or experience, or political traction necessary to proceed with the reconstruction in a systematic way.

In the chaotic situation prevailing at the very beginning, MoPH leaders who did not have much public health management knowledge and experience were very cooperative and remained open to good ideas and exchange of views.

Diverse and often divergent points of view were present and needed to be heard and analyzed, while pressure to make important policy decisions rapidly was real.

The representatives and experts from the international agencies helped us with the process of defining the strategic and operational options and opportunities. During the initial phase of reconstruction, they played a determinant role in designing and describing the governance process and guidelines for all stakeholders to be mobilized, and consulted in the decision-making process. 

The international community in general and donors such as USAID, the World Bank, and the European Commission in particular demonstrated all along a high degree of focus, patience, and stability in their support. This was particularly true during the sensitive initial phase when the Afghan governance mechanisms were not quite fully back in place yet.

But really, this strength of purpose has been constant and sustained since 2002 and up until today. Without the judicious and steady leadership, technical and financial support, and management demonstrated from the outset by our international counterparts, the Afghan health system would have taken much more time achieving today’s results. One cannot overstate how exceptional this joint effort and cooperation has been.

The various critical policy decisions made, such as the definition of the basic package of health services (BPHS), the contracting out of health services to NGOs, and the MoPH focusing on a stewardship role have proven to be right ones.

BPHS, use of NGOs for provision of primary health care service, and the MOPH Stewardship role allowed for a smoother, more systematic and better organized way of addressing the six building blocks of health system strengthening in Afghanistan. These wise policy decisions and their effective implementation could not have been possible without the good governance and leadership manifested by all the Afghan and international partners and decision-makers.

MSH: Based on your experience and looking forward, what are in your opinion the most important challenges facing the Afghan health system today and in the future?

Dr. Mubarak: We can see today that health programs have better success where and when leadership, management, and governance are better. Some regions which have benefited from such capable leaders and managers for many years (such as Herat) are shining better.

But other regions are improving as well. Even Khost province which was quite unstable for a long time is now in a better situation when it comes to its governance and management, and health indicators there show good progress at last. MoPH in Afghanistan is capable of managing resources in very professional and transparent ways, and this ability and strength of the MoPH encouraged donors to channel more resources through the government for BPHS implementation and health system strengthening.

Continuing to strengthen Afghan capacity in inspired leadership, sound management, and transparent governance is among the top priorities to consolidate the gains achieved, and move us toward a truly sustainable health system.

Our international counterparts from the start and the Afghan leaders now have shown good capacity and practice in ensuring stakeholders are properly engaged in the sector’s reform, and in setting direction.

The Ministry of Public Health now has in place a best practice mechanism such as the various specialized technical working groups, a consultative committee, and an executive decision- making mechanism in which stakeholders inputs and participation play a critical role.

One of the goals of the health sector is to see the capacity of the Ministry continue to grow in playing its stewardship role so that the decentralization of the health system is effective, and produces all of its promises of improved efficiency and better health services to the population. Intensifying our efforts and focusing on cultivating accountability across the sector is also an important challenge, and a goal for Afghans as we strive to strengthen our country and increase its stability.

Interview By Alain Joyal, MBA, CPA, Country Programs Team Leader, Management Sciences for Health

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