Intended for healthcare professionals

Analysis Making Multisectoral Collaboration Work

Scaling up primary health services for improving reproductive, maternal, and child health: a multisectoral collaboration in the conflict setting of Afghanistan

BMJ 2018; 363 doi: (Published 07 December 2018) Cite this as: BMJ 2018;363:k4986
  1. Jai K Das1,
  2. Nadia Akseer23,
  3. Shafiq Mirzazada4,
  4. Zahra Peera1,
  5. Omarwalid Noorzada2,
  6. Corinne E Armstrong5,
  7. Kashif Mukhtar1,
  8. Ahmed Jan Naeem6,
  9. Zulfiqar A Bhutta123
  1. 1Center of Excellence in Women and Child Health, Aga Khan University, Karachi, Pakistan
  2. 2Centre for Global Child Health, The Hospital for Sick Children, Toronto, Canada
  3. 3Dalla Lana School of Public Health, University of Toronto, Canada
  4. 4Aga Khan University, Kabul, Afghanistan
  5. 5Independent, London, UK
  6. 6Ministry of Health, Government of Afghanistan
  1. Correspondence to: Z Bhutta zulfiqar.bhutta{at}

Jai Das and colleagues present an innovative and evolutionary model of multistakeholder and multisectoral collaboration in scaling up coverage of health services in Afghanistan

Owing to the longstanding civil war after the Soviet invasion of 1979, neglect of the social sector, and subsequent political instability, Afghanistan faced economic collapse in 2001, with compromised infrastructure and extremely limited capacity for delivering health services.1 Compounded by complex geography and widespread poverty, Afghanistan’s health and survival indicators were among the worst globally. The average life expectancy was only 44.5 years, and the estimated maternal mortality ratio (1600 per 100 000 live births) and infant mortality rate (165 per 1000 live births) were alarmingly high.2 Recurrent illness and suboptimal infant and young child feeding and hygiene practices led to high rates of childhood undernutrition.3 Coverage of essential reproductive, maternal, newborn, and child health interventions was abysmal, with skilled birth assistants at only 14% of births and safe drinking water being available to <40% of the population.4 Access to health services was also poor, with only 10% of the population living within one hour’s walking distance of a health facility.5 Economic and social indicators had waned after three decades of war—only 30% of Afghans were literate (only 5.7% of females) and annual gross domestic product (GDP) per capita was about $199 (£156; €176) (see section 1 of supplementary file).46

Afghanistan’s priorities in 2001 were to rapidly increase access to primary healthcare and to prioritise key interventions, such as basic civic services, education, food security, and childhood immunisations, particularly for rural and underserved populations. Meanwhile the government embarked on longer term, multisectoral planning. Afghanistan introduced the Basic Package of Health Services (BPHS) in 2003 through a process of innovative multisectoral collaboration that encompassed devising, implementing, scaling, and iteratively refining …

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