This New Project Is Improving Health Care Quality in Afghanistan

As Afghanistan works to rebuild itself after many years of conflict, the country’s health care system remains an area of concern. Despite recent significant improvements, access to health care remains a challenge for many Afghans, particularly those living in remote or rural communities. In addition, the outdated infrastructure, lack of critical amenities and facilities, and inadequate opportunities for medical training that are standard in most parts of Afghanistan mean that it can be difficult for providers to deliver health care beyond the most basic services.

However, Afghanistan’s health care system is set to get a major boost over the next few years through the Sehatmandi Project, a large-scale program launched in the summer of 2018 that aims to improve access to and quality of health care services across the country. Here are four things you need to know about this important project.

It will cover the entire country.

Many of the development programs or initiatives that deal with health care in Afghanistan do so in very targeted areas, often concentrating either on Kabul or on rural areas in the north of the country. The Sehatmandi Project is exceptional in that its scope includes 31 of Afghanistan’s 34 provinces. This means that Afghans all around the country will be able to benefit from the cohesive and holistic improvements to Afghanistan’s health care system that the project aims to implement. In addition, some of the project’s key focus areas include offering underserved populations beneficial services such as nutrition management and family planning programs.

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It is supported by a variety of national and international partners.

The Sehatmandi Project is a major, multi-year initiative with a budget to match: the total cost for the program’s three years of operation is estimated at US$600 million.

This cost will be covered by grants from three major funding entities:

The Afghanistan Reconstruction Trust Fund (ARTF)—Established in 2002, this multidonor trust fund is supported by 34 international donors under the overall management of the World Bank. It is one of the most important entities supporting Afghanistan’s ongoing rebuilding and development process.

The International Development Association (IDA)—Another arm of the World Bank, the IDA provides loans and grants to some of the world’s poorest countries, with the aim of boosting economic growth and lifting these nations out of poverty.

The Global Financing Facility (GFF)—This multi-stakeholder partnership helps governments of low- and lower-middle income countries to prioritize and finance their citizens’ health and nutrition.

In addition to these three major funders, the Sehatmandi Project involves many other administrative and operational partners, including Afghanistan’s Ministry of Public Health and Health Works, a global NGO based in the Netherlands.

It aims to build on the successes of a previous program.

The Sehatmandi Project is a follow-up to the System Enhancement for Health Action in Transition (SEHAT) program, another initiative operated by Afghanistan’s Ministry of Public Health and supported by IDA and ARTF.

Running from January 2014 to June 2018, SEHAT aimed to expand the scope, quality, and coverage of health care services provided to Afghans, especially vulnerable and underserved populations. A key goal of SEHAT was to allow health facilities across Afghanistan to deliver a basic package of health service (BPHS) and an essential package of hospital service (EPHS). The successes of the SEHAT program have laid an important foundation for the Sehatmandi Project, which can now pick up where the earlier program left off and take its accomplishments to the next level.

Some of the most important achievements of the SEHAT program include the following:

Better health services in Nangarhar province—SEHAT oversaw new health initiatives in each of Nangarhar province’s 22 districts. For example, with the support of the SEHAT program, personnel at the Kama District Hospital were able to upgrade their skills and provide better care to patients, and the hospital itself received a second ambulance and a power generator.

The Kabul Urban Health Project—The Rahman Mina Hospital, a Kabul hospital that serves hundreds of thousands of the city’s residents, benefited from extensive renovations and new equipment provided under SEHAT. In addition, the hospital was able to increase its supply of critical medicines, and hospital staff received training on a new health management information system, which improved the facility’s operational efficiency.

It now includes a pay-for-performance component.

In early 2019, Aga Khan Health Services (AKHS) took over the management of health care facilities in two Afghan provinces under the umbrella of the Sehatmandi Project. In this new role, AKHS will be responsible for two provincial hospitals, five district hospitals, 24 comprehensive health centers, 158 basic and primary health centers, and more than 1,000 village health posts in the provinces of Bamyan and Badakhshan.

Interestingly, AKHS plans to operate its portion of the health system using a pay-for-performance model, which will see health service providers compensated for meeting pre-established benchmarks, including numbers of antenatal and postnatal care visits, numbers of immunized infants, and quantity and quality of major surgeries.

Spotlight on the Chihilsitoon Garden Restoration Project

The Aga Khan Trust for Culture (AKTC), one of the affiliate agencies of the Aga Khan Development Network, has a long history of supporting and working on cultural restoration and rehabilitation projects in some of Afghanistan’s most important cities. In fall 2018, AKTC celebrated the completion of its most ambitious project yet: the restoration of Chihilsitoon Garden, the largest historic public garden in Kabul. Read on for a closer look at this exceptional rehabilitation project.

What is Chihilsitoon Garden?

The historic Chihilsitoon Garden and Palace occupy a 12.5-hectare site in the Afghan capital of Kabul. Originally created as a royal garden in the 19th century, the park became state property in the early 20th century. During this part of its history, Chihilsitoon Garden welcomed visiting international dignitaries such as US President Dwight D. Eisenhower and Soviet Premier Nikita Khrushchev. Chihilsitoon Garden was severely damaged and looted during periods of unrest in Afghanistan, and the neglected site was left in disrepair for more than two decades.

The goal of the Chihilsitoon Garden rehabilitation project was to restore this once-beautiful site to its former glory and, in so doing, provide Kabul’s approximately 4.5 million residents with more space for recreational and communal activities, add much-needed green space to the city to help improve its air quality and climate, and provide the local population with jobs and the opportunity to acquire new skills. Now that the restoration is complete, the garden will be managed by the recently formed, independent Kabul Historic Gardens Trust (a new iteration of the Bagh-e Babur Trust, which has been sustainably operating the historic site of Babur’s Gardens for over 10 years).

What work was carried out during the Chihilsitoon Garden restoration?

The Chihilsitoon Garden restoration involved extensive rehabilitation work on virtually all aspects of the site. Particular projects included:

Extensive landscaping of outdoor space—The heart of the restored Chihilsitoon Garden site is a historic formal axial garden (a type of symmetrical design commonly used in traditional Islamic gardens), which is surrounded by areas of dense landscape and open lawns. Radiating outwards from this garden is a network of paths and trails that link and encompass a variety of spatial experiences, including group picnic areas; an outdoor amphitheater; and the historic formal promenade, which features the garden’s now-restored, fully functional original marble fountains. As part of this extensive landscaping work, more than 5,000 new trees were planted throughout the site.

The creation of new buildings and amenities for public use—One of the main functions of the restored Chihilsitoon Garden is to serve as a multi-purpose gathering place for communal events of all kinds. To this end, a number of new public buildings were constructed throughout the park, including an exhibition hall; a 300-seat auditorium; buildings for administration, maintenance, and visitor management; and a multi-purpose facility created inside the reconstructed historic Chihilsitoon Palace. To complement the garden’s historical legacy, these contemporary buildings were designed in keeping with traditional vernacular style and constructed using local building methods and materials. (Interestingly, the main building material used was rammed earth: highly suitable for the region’s climatic and ecological environment, rammed earth has been used for construction in Afghanistan for two millennia. In Chihilsitoon Garden, the newly constructed rammed earth buildings were reinforced with bamboo trees and steel rebar to improve earthquake resistance.)

The creation of sites and facilities for sports activities—Chihilsitoon Garden is also envisioned as the home of a variety of sports and outdoor recreation activities. A distinct zone in the restored park contains cricket batting areas, outdoor volleyball courts, and two mini football fields. A building with indoor changing facilities and showers was also constructed to improve the park’s capacity to host competitive sports matches.

Revenue-generating amenities—Part of the Chihilsitoon Garden restoration project was to build in sources of income generation that could eventually help the park to become financially self-sustaining. For example, the garden now includes retail units, food kiosks, and restaurants that can be operated or rented out to generate ongoing revenue. The garden is also home to a commercial horticulture nursery, which can generate revenue in addition to maintaining the stock of trees and plants within the garden.

Utility upgrades—Careful consideration was given to the question of utilities in the garden during the restoration. While provisions have been made for on-site utilities, the garden has been designed to necessitate limited use of water and electricity due to features like septic systems that filter wastewater through subsurface leach fields.

What other partners supported the Chihilsitoon Garden restoration?

The Aga Khan Trust for Culture worked closely with many partners and supporters to complete the restoration of Chihilsitoon Garden and Palace. These include Kabul Municipality, the Afghan Ministries of Culture and Urban Development, and many local communities in Kabul. Funding for the project was provided by the German Federal Foreign Office through the KfW Development Bank.

Spotlight on the Art of Traditional Afghan Construction

Buildings in Afghanistan have been constructed using traditional methods for many centuries. Developed in response to Afghanistan’s unique building challenges—including extreme climate and weather conditions, frequent earthquakes, and varying availability of natural resources—these traditional techniques have withstood the test of time. Except for the incorporation of a few modern adaptations like plumbing and electricity, many Afghan buildings today are constructed in the same way that they have been for hundreds of years.

One excellent recent example of the use of traditional building methods on a large scale is the restoration of Kabul’s historic Murad Khani neighborhood by the nonprofit organization Turquoise Mountain. To bring the neglected buildings of this area back to their former glory, hundreds of artisans and community members used traditional construction techniques to restore and refurbish—and in some cases reconstruct— homes and other structures more than two centuries old.

The new Preserving Afghan Heritage platform, now available on Google Arts & Culture, offers visitors an absorbing look at the Murad Khani restoration, including a fascinating online exhibit on the traditional methods used during the project. As described in the exhibit, the steps involved in traditional Afghan building include the following:

The foundation

Creating a strong foundation is the first step in the traditional building process. Foundations, which are often dug out by hand, must be able to support the planned building. This means that taller buildings will require deeper foundations. Once the excavation is complete, the pit is filled in with stone and rubble, and then topped with another layer of stone. Roughly 40-60 centimeters high, this final layer ensures that the earth walls are elevated above ground level, which helps to protect them against the weakening effects of rain and snow.

The exterior walls

The main skeleton of the building is constructed using a technique known as senj, in which bricks are placed inside a timber frame. The timber skeleton is constructed first: vertical wooden poles are placed around the perimeter of the building about 60-70 centimeters apart and are then secured to the horizontal wooden beams of the floor and ceiling. Next, the spaces between the poles are filled with bricks. With the senj technique, the bricks are laid diagonally between the poles; after seven to 10 layers have been completed, the bricks are then laid in the opposite diagonal direction. These alternating directional layers help strengthen the walls of the building and improve its resistance to earthquakes.

Image by Jim Kelly | Flickr

The roof

To increase the stability of the roof, builders place layers of woven bamboo and willow branches onto the roof beams and secure them in place. Ghora gel, a mud mixture, is then applied to the branches to stabilize them and seal the roof. Note that the roofs and ceilings of traditional Afghan buildings are low to help keep interior rooms warmer during the cold winter months.

The interior walls

In a traditional Afghan building, the interior walls are built with the same senj technique used for the exterior walls. Vertical poles are placed to define the perimeter of the rooms and are then filled with diagonal layers of bricks.

Interior finishes

Once the electrical wiring has been installed, the interior walls are covered with a plaster made from mud, straw, and water. This plaster is left for a day to dry, after which the seemgel is added. Seemgel is a type of interior finish composed of screened mud, water, and lokh (a traditional Afghan construction material made of a mixture of clay and the downy fluff of reeds). Seemgel is applied to the interior walls in layers, with a drying time of two days required between layers. It is mainly used for buildings where the intention is to decorate the interior walls.

Windows and doors

Because it was challenging in the past to construct fixed windows with hinges, many traditional Afghan buildings use patayi screens instead. These are horizontal windows stacked on top of each other, which can be raised separately in order to control and direct air circulation in the room. In the summer, for example, the patayi screens are typically raised to maximize airflow and keep the interior cool. As for the door frames, these are deliberately kept very low so that visitors must bow when they enter, thereby showing respect for the house’s owners.

Decorative touches

Depending on the means of the owners, there are many different decorative touches that can adorn the finished interiors of traditional Afghan buildings. For example, the ceiling may be covered with carved wooden panels fixed directly to the roof beams; not just visually appealing, this has the practical benefit of preventing dust or dirt from the roof from falling into the rooms. It’s also common to set hand-framed, plaster niches into the interior walls so that ornaments and pictures may be displayed. Sensibly, there are usually two different heights of niches—the higher ones, out of the reach of children, are where more fragile items are kept.