Conduct annual assessments to evaluate the quality of service, opinion and attitudes towards and community involvement in health care in all 34 provinces of Afghanistan
Train and advise Ministry of Public Health provincial and central level staff to improve the monitoring and evaluation of health care services
Assist the Ministry of Public Health as they strive to deliver a basic package of health services
Design, implement and evaluate innovative health care financing pilot projects in selected provinces
Burnham G. Maternal Mortality among Afghan refugees. Editorial commentary, Lancet, 2002;359:639-40
Smith J, Burnham G. Conception and Death in Afghanistan. Editorial Commentary, Lancet 2005, Lancet. 2005,365:827-8.
To view photos taken by Dr. Burnham in Afghanistan, please follow this link to the article in the Baltimore Sun
Results from assessments conducted by researchers from the Johns Hopkins Bloomberg School of Public Health and the Indian Institute of Health Management Research show substantial improvements in the health status of the people of Afghanistan after decades of conflict. From 2004 to 2006, the health system has shown improvement for many key measures in a majority of provinces. These results demonstrate that improvements in health service delivery have been achieved across the country in a rather short period of time, according to the researchers. The results from the assessments were presented to the Ministry of Public Health in June.
“The delivery of public health service is improving steadily in Afghanistan as the Ministry of Public Health makes progress towards meeting its goals,” said principal investigator Gilbert Burnham, MD, professor of international health at the Bloomberg School of Public Health and director of the Center for Refugee and Disaster Response. “Despite these gains, health facilities in Afghanistan have room for improvement in several areas.”
The researchers utilized the Balanced Scorecard—a tool designed to rapidly measure key components of basic health services—to assess and manage public health services countrywide.
For 2006, the Afghanistan Health Sector Balanced Scorecard showed continued performance improvements in health facilities across the country. Driving these advances were increased availability of essential drugs and family planning supplies, improved quality of patient care, increased provision of antenatal care to pregnant women, upgraded skills among health workers, increases in the number of female health workers providing care throughout the country and relatively high levels of patient satisfaction.
According to the 2006 assessment, more female patients than male patients used outpatient services, and the poor were more likely to use public sector services than the non-poor, which is in line with the Ministry of Public Health’s stated goal for equitable health care. Additionally, household surveys implemented by researchers from Johns Hopkins and the Indian Institute of Health Management Research in late 2006 estimated that of every 1,000 children born in Afghanistan, on average 129 die in the first year of life (infant mortality rate) and 191 die before reaching the age of five years (under-five mortality rate). The surveys covered more than 8,200 households in rural areas in 29 provinces of Afghanistan. Previous estimates from UNICEF for the year 2000 place the infant mortality rate in Afghanistan at 165 per one thousand live births and the under-five mortality rate at 257 per one thousand live births.
The percentage of women in rural Afghanistan receiving antenatal care during pregnancy from a skilled provider increased from an estimated 4.6 in 2003 to 32.2 in 2006. Over the same time period, the percentage of women in rural Afghanistan who had a doctor, nurse or midwife assist with their last delivery increased from 6.0 to 18.9.
More children are receiving vital childhood immunizations, according to the assessments. The percentage of children 12-23 months of age in rural Afghanistan who received the BCG vaccine to protect against tuberculosis increased from an estimated 56.5 in 2003 to 70.2 in 2006. The percentage of children 12-23 months of age in rural Afghanistan who received the full dosage of oral polio vaccine increased to 69.7 in 2006, from 29.9 in 2003.
The researchers found improvement was needed in the management of tuberculosis treatment, laboratory services, reaching women for care during pregnancy and delivery, and health workers spending a sufficient amount of time with each patient.
“While deaths of infants and children under age five in Afghanistan remain high and the level of coverage of health services is still below the ideal, these results indicate that substantial progress has been made in improving the health of the people of Afghanistan since 2003,” said Burnham.
The assessments were funded by the Ministry of Public Health through grants from the World Bank.
"Afghanistan Health Sector Balanced Scorecard National and Provincial Results"
Helping to bring health to Afghans Profile: Dr. Gil Burnham
By David Kohn
August 27, 2006
As a U.S. Army physician working in South Korea in the late 1960s, Dr. Gil Burnham took care of sick and injured GIs. But as an unofficial side project, he and the group of medics he supervised spent most weekends traveling the South Korean countryside, caring for villagers.
"I discovered I could order any amount of medicine through the Army supply system, and nobody asked questions," Burnham says. "There was a huge amount of tuberculosis, so we started these TB clinics."
He had found his calling. "After about six months, I thought, 'I really like this. Can you do this for a living?' "
The answer, it turns out, is yes.
A professor of international health at the Johns Hopkins University Bloomberg School of Public Health, Burnham has spent much of the past four decades working all over Africa and Asia, helping very sick, very poor people.
"He's made it his life's work," says his friend David Peters, a Bloomberg professor and collaborator on a venture to help rebuild the health-care system of Afghanistan, one of the least healthy countries on the planet.
Burnham and a staff of 26, many of whom work in Afghanistan, are literally part of the country's Ministry of Public Health. They have offices in the headquarters in downtown Kabul and meet regularly with top officials. Their job: to provide health data to the ministry, which has little experience undertaking health research.
He is based in Baltimore but has made 15 trips since the project began in 2002, usually traveling around Afghanistan to see firsthand how the work is going.
"I've been in the field with certain people who never get out of the Land Cruiser," says Dr. Ayan Noor, who until recently was the in-country manager for the project (she now works in Liberia for the U.S. Agency For International Development). "Gilbert is always the first one out, bounding ahead of us."
A tall, lanky man with a trim beard and horn-rim glasses, Burnham, 64, has the air of a wry academic. Noor says that on trips around Afghanistan, people invariably ended up calling him "Professor."
Since the United States ousted the Taliban regime five years ago, millions in international aid from the United Nations and the World Bank have been devoted to rebuilding Afghanistan's health-care system.
For the past four years, Burnham's project has been advising the Afghan government where it should focus its efforts. The funding for the project—about $2 million so far—comes from the government, which receives the money from the World Bank.
Burnham's group tracks statistics such as infant mortality rates, patient and health worker satisfaction and the percentage of prescription drugs that are counterfeit or substandard. This information plays a key role in shaping the fledgling health-care system.
Dr. Faizullah Kakar, acting minister of public health, says in an e-mail that Burnham is a "valuable addition to the ministry," and calls him "courageous and dedicated."
Their work has already produced tangible change. For example, the Afghan government increased resources to fight tuberculosis after researchers reported that health clinics and hospitals offered little treatment and kept poor records. Such records are especially crucial because most TB patients require careful daily care. "This is not just an abstract exercise," says Peter Hansen, director of the project's Kabul office. "Our findings lead to concrete results."
Burnham sees signs that health care is improving: Patients are getting better treatment, the number of health workers is growing, and training is more widespread. The next problem he hopes the project will address is the state of hospitals, which remain severely understaffed and underequipped.
The project was started by Burnham and Peters. They began studying a few provinces, but the Afghan government asked them to cover the entire country. Peters now works mostly at the World Bank, and devotes less time to the project. Burnham oversees the day-to-day work, communicating constantly by e-mail and Internet phone with colleagues in Afghanistan.
Research has become more difficult as Taliban fighters have reasserted themselves in large swaths of the country. According to the United Nations, the number of security incidents—bombings, shootings, etc.—were greater last month than at any time since the fall of the Taliban in 2002.
Several months ago, the Taliban fired upon a survey team driving in central Afghanistan. Luckily, no one was hit. Over the past year, the project has stopped doing research in several provinces because the risk is too high.
Even without the threat of violence, Afghanistan's conservative culture presents challenges for researchers. In many areas, women are not allowed to speak to men who are not relatives, so male-female teams are required. Survey materials are touchy, too.
Earlier this year, Burnham and his team planned to measure patient satisfaction by asking people to choose one of four smiley faces ranging in mood from gloomy to happy.
No way, said Afghans who were providing input. "People said 'Uh, this is a very fundamentalist area, where you cannot have any image of a living being'," Burnham recalls.
How about images of money, with higher values connoting increased satisfaction? Locals didn't like that idea, either, saying it suggested gambling, a forbidden practice in much of the country.
After more discussions, the researchers finally began to grasp the Afghan perspective: They developed a rating that used drawings of loaves of bread, with more loaves signifying better care. "Everybody eats bread there, wheat is the big crop," says Burnham. Patients "caught onto that instantly," he says. "It was an incredible hit."
Once a reasonably healthy place by Third World standards, Afghanistan has plummeted to the bottom ranks of many international indicators. Three decades of almost constant warfare have decimated the country's health-care system.
Over their lifetime, Afghan women who give birth have a one-in-nine chance of dying during childbirth. In Africa, the rate is one in 16; in the United States, it is one in 2,500. The country's average life expectancy is 53, and its infant mortality rate is about 170 deaths per 1,000 births. In Baltimore, a city that has one of the highest rates in this country, the rate is 13 deaths per 1,000 births.
A few months ago Burnham took part in a workshop with villagers in a rural province. He posed a question to a group of women: Given unlimited resources, what would they like to be doing in five years? The response surprised him.
"The most common answer was, 'In five years, I'd like to be alive.' That was really sobering," he says.
In choosing his career, Burnham followed a family tradition. Both of his parents, a streetcar driver and a nurse, were interested in social justice. And as a child growing up in Los Angeles, Burnham heard many stories from his uncles: One was a surgeon for a mission hospital in Manchuria; another was a relief worker elsewhere in China, a third was a pathology professor in India.
After serving in South Korea, Burnham was assigned to be deputy director of a military hospital in Alabama. The director was near retirement and ready to relax; Burnham was soon running the hospital. To his surprise, he found that he enjoyed writing budgets, crafting reports, and performing the day-to-day detail work of keeping an institution running smoothly. Since then, he has used his talent for administration repeatedly.
After his discharge, he studied public health at the London School of Hygiene & Tropical Medicine, and in 1977 found a job as a doctor at a hospital in Malawi, a poor, agricultural nation in southern Africa.
Within months, he was running the place. Over the next few years, he rebuilt and re-equipped it until the hospital was the best in Malawi. He worked 80 hours a week, 40 as a clinical doctor and 40 as an administrator. His highest salary was $14,000 a year.
During the early 1980s, he got a call in the middle of the night telling him to come to the palace of the country's brutal dictator, Hastings Kamuzu Banda, who was almost certainly in his 90s. Banda, himself a doctor, was very sick. A jittery Burnham drove an hour into the principal city, Blantyre, and found Banda breathing with difficulty, his lungs full of fluid.
With lackeys and thugs hovering, Burnham diagnosed partial heart failure. Luckily for both patient and doctor, Burnham prescribed the proper medicine, and Banda recovered. From then on, Burnham was the dictator's personal physician.
After more than a decade in Malawi, Burnham decided that he needed a new challenge. "I wanted to see if my brain still worked," he says. He had spent years dealing with what he calls "five-minute problems" - how much medicine to give a particular patient, or where to get money to fix a broken generator - and wanted to think about problems from a wider perspective.
So he went back to London for a doctorate in public health and within a few years was recruited by Hopkins. (Banda was still alive when his doctor departed. He died in 1997 at the age of 99, three years after losing power in an election.)
Soon Burnham started the Center for Refugee and Disaster Response, which provides guidance to public-health workers on the most effective ways to handle humanitarian emergencies. The group has worked in most of the world's refugee hot spots, including Africa, the former Yugoslavia and the Middle East. He remains co-director of the center.
He is probably best known for his controversial 2004 study of Iraqi civilian health, which found that the U.S.-led invasion had led to 98,000 additional deaths. The research appeared in the British medical journal The Lancet.
Burnham and his co-authors do not argue that coalition military forces directly caused all or even most of the deaths. They say that in the chaos after the invasion, disease became more rampant and medical care more inaccessible.
In addition to his work in Afghanistan, Burnham is involved in a partnership with schools of public health in Tanzania and Uganda to increase training, and a study of the health of North Korean refugees who have escaped to China.
Burnham and his wife, Ginny, a psychologist, live in Baltimore—within a shuttle-ride of his office, allowing him to avoid driving.
Despite having lived here for 15 years, he is still affected by reverse culture shock.
"In Malawi, we saved all our plastic bags," he says. "You never drove your car unnecessarily. If you could walk, you walked instead."
And he retains his impulse to hoard.
"When I go to the store and I see something I want, I buy a lot," he says, laughing. "I come back and my wife says, 'Gilbert. We really don't need five of those.' "