Provinces Of Afghanistan Research Articles

Can community health workers increase coverage of reproductive health services?

BackgroundHealth services were severely affected during the many years of instability and conflict in Afghanistan. In recent years, substantial increases in the coverage of reproductive health services have been achieved,...

Water for agriculture: challenges and opportunities in a war zone

Wars, drought and social collapse have greatly impaired land management and agriculture production systems in the southeastern Afghanistan provinces of Khost, Paktika and Paktya. This region has long existed with limited central government influence and remains particularly unstable. A complex physical and social geography, on-going warfare, severely limited mobility and policies poorly adapted to regional realities hamper development and reconstruction. On-farm water efficiency improvement, watershed-scale work restricted to small, socially homogeneous watersheds and word-of-mouth Afghan-to-Afghan technology dissemination are particularly important development strategies in this environment.

Improvised Explosive Devices in Southern Afghanistan and Western Pakistan, 2002–2009

Homemade bombs or improvised explosive devices (IEDs) are staple weapons of conflicts in South Asia and especially Southern Afghanistan and Western Pakistan, where the Taliban, their affiliates, and other armed groups use them to undermine recognized governments and policies. This study establishes IED trends in the Afghanistan provinces of Helmand, Kandahar, and Nimroz and the Pakistani province of Balochistan between 2002 and mid-2009, using geo-referenced open source IED event information and statistical or geospatial analysis techniques. This study also furnishes assessments of specific IED technologies, techniques, and procedures (TTPs; like explosively formed projectiles or radio-controlled “spider devices”) as well as discussions of their potential causes and observable effects. There are several major trends observed: a continuous increase in volume and lethality of attacks, more expansive geographic distribution of attacks, and multiple bombing campaigns overlapping in Quetta, Balochistan province, that are perpetrated by groups with different means, tactics, and objectives. The most IED-related violence occurred in Kandahar province from 2002–2008; however, Helmand province was the leading location of bomb events by early 2009. Although large population centers—such as the cities of Kandahar, Quetta, and Lashkar Gah in Helmand province—commonly experienced effective bombings, the trans-border routes through Zaranj in Nimroz province and Spin Boldak in Kandahar province were also prone to many lethal attacks. In particular, this study both confirms and scrutinizes the so-called Iraq effect, the phenomenon of knowledge-sharing between fighters in Iraq and Afghanistan. Even though fighters who gained experience in the Iraq insurgency provided assistance and training to Taliban fighters, the evidence indicates that some developments in IEDs predated the Iraq conflict or were original to South Asia or other conflicts in history. This evidence provides support for a more generalized and global phenomenon here called “TTP acceleration,” whereby insurgent and terrorist advances in IED capabilities take progressively shorter periods of time to develop and transfer among groups, usually as a result of increased information-sharing opportunities and coincidental alignment of group objectives.

Share of Afghanistan populace in hepatitis B and hepatitis C infection's pool: is it worthwhile?

There is a notable dearth of data about Hepatitis B Virus (HBV) and Hepatitis C Virus(HCV) prevalence in Afghanistan. Awareness program and research capacity in the field of hepatitis are very limited in Afghanistan. Number of vulnerabilities and patterns of risk behaviors signal the need to take action now.Thirty one studies dating from October 2003 to 2011 were included, consisting the data of 1,32,981 individuals for HBV and 1,32,500 individuals for HCV. Percentage prevalence was 1.9% for HBV and 1.1% for HCV in all available Afghanistan population. Most at risk population to hepatitis include injecting drug users who share needles and female sex workers, while truck drivers, prisoners and homosexual men needs attention, as their statistical figure are missing. Data suggests that high incidence of intravenous drug use, sexual activities, unsafe blood transfusion procedures and mobility are major risk factors for hepatitis transmission.This review is based on analysis of the limited available data in Afghanistan. Although there are many underlying vulnerability factors, it appears that Afghanistan remains at an early epidemic phase. Further research is required to determine the seroprevalence and prevalent genotype(s) of HBV and HCV in all provinces in Afghanistan. This article provides some key insights into the potential and likely future transmission dynamics of Hepatitis which will serve as a guide in the identification of priority areas in term of high risk groups and risk behaviours in the country and will assist to develop urgent strategic plans to combat the future burden of Hepatitis in Afghanistan.

A Land Untouched by Dentistry – Singapore Brings Dental Care to Afghanistan

In 2007, the Singapore Armed Forces deployed a Dental Project Team (DPT) to the capital city of the Bamiyan Province in Afghanistan. The team set up the province's first modern dental facility. Besides providing primary dental care to the 60,000 population there, the Singaporeans also trained and prepared a team of Afghan dentist and dental assistants. The Afghan dental team took over the dental clinic and continued to provide care when it was time for the DPT to depart for home. Braving challenging security and austere living conditions, the DPT completed its mission successfully.

Archaeological heritage and problems of its preservation in Ghor province, Afghanistan

Heritage of the Ghor province has not been protected and is still being devastated by long years of war actions. Archaeological researches have almost never been made in Ghor province of Afghanistan. Therefore, a lot of archaeological monuments have never been localized and still are damaged by human actions or by nature, influenced by natural erosion. Lithuanian archaeological expedition in the province of Ghor is a constituent part of the long-term program "Archaeological - heritage mission in Ghor province, Afghanistan, 2007-2010". This program is dedicated to the preservation and registering of the archaeological heritage of Ghor province in Afghanistan. Within the distance of 60 km from the centre of province Chaghcharan, archaeological sites of value were visited and registered. Register certificates were started for 11 archaeological sites discovered in autumn 2007 as well as for 9 ones found in spring 2008. Ghor province is full of easily recognizable objects of archaeological heritage: Ancient settlements (tapa), which have chronology from Eneolithic and Bronze Age to the Islamic period of the Middle Ages; Remains of castles and fortresses from the 1st millennium A.D.; Monuments from Buddhistic period - monastery of Vayguna Sange Bar (first half of the 15th millennium); Remains of settlements and cult objects of Kabre Zabok; Monuments of technology and engineering - mills, brickyards, ruins of bridges, caravanserais - still exist in many places. One of the aims of the archaeological - heritage project is training local heritage specialists to use modern technologies for the registering cultural valuables and for the heritage preservation purposes. During researches, damage made to the cultural valuables and possible dangers are analyzed. Recommendations about their protection are given as well. The Register of archaeological monuments in Ghor province that has been started by Lithuanian archaeologists is yet the one and only in Afghanistan.

Primary care in post-conflict rural northern Afghanistan

Little is known regarding the nature of primary care in post-conflict communities for several reasons, including: data collection is often given a lower priority than the immediate medical care needs in emergencies; and dynamic changes in a patient population and their needs make it difficult to collect data over the long term. Kinderberg International, e.V. is a German humanitarian organization that has been providing primary care in northern Afghanistan for the past 3 years. The aim of this article is to provide demographic data, pattern of clinic visits and descriptive epidemiology of the large data set from the primary care units. Observational study. Patient data gathered using the standardized government tally sheet were reviewed for 1 January to 31 December 2008. The data contained information from 12 primary care clinics and mobile clinics in three northern provinces in Afghanistan. In 2008, the 12 primary care clinics had more than 250,000 clinical encounters. There were significantly more visits due to diarrhoea and dehydration during the summer months. Overall, the number of primary care clinic visits showed clear seasonal variation, while the number of visits to mobile clinics remained stable throughout the year. Forty-three percent of all clinic visits were due to acute respiratory tract infection and diarrhoeal diseases, and 43% were due to uncategorized diagnoses. Based on the data from three provinces in northern Afghanistan, mobile clinics can be an effective method to provide medical care in remote areas. A substantial proportion of diagnoses in patients at the clinics was not classified into pre-defined disease categories; these patients presented with numerous symptoms needing treatment. The high volume of ill-defined visits with various complaints to primary care clinics in emergencies may support the claim that primary care clinics are providing more than medical solutions, but also provide care for various complaints and an indispensable safety net to communities under stress. From this standpoint, primary care clinics in post-conflict communities should be considered as a vital element of peace building.

Construction contracting and civil–military interaction

There is a need for improved insights into the contracting process for construction projects that the military contract out to civil contractors in the specific setting of civil–military interaction (CMI) in regions that are suffering from instability and armed conflict. The core questions are: what are the key criteria for contracting out CMI projects in out‐of‐area operations, and what contracting methods are appropriate? First, we discuss possible methods and key criteria for contracting out CMI projects. Following this, a case study based in the Uruzgan province of Afghanistan explores key criteria for contracting out CMI projects. Based on this case study, the following five CMI‐related criteria have been identified: generating information on the civilian environment; contributing to building local capacity; process transparency; force acceptance and local participation; and contracting as a tool for stability. These criteria dominate more regular criteria such as cost and time. Some methods frequently used in developed economies, for example the open public tender procedure, seem less appropriate when contracting out CMI projects within a military mission. In CMI projects, contracting most closely resembles the multiple negotiated tender procedure. Future projects can use the identified range of methods and key criteria in designing an improved contracting process.

Peering into the Fog of War: The Geography of the WikiLeaks Afghanistan War Logs, 2004-2009

A team of U.S. political geographers analyzes the secret Afghanistan war logs released by WikiLeaks.org. They offer the chance to examine in detail the dynamics of the conflict in that country. Doing so in a spatial framework is possible because each of the 77,000 events has geographic coordinates and dates. Using cartographic and geostatistical tools, the authors map the changing distribution of the events and compare them to the well-known violent-events ACLED database (see O'Loughlin et al., 2010 in this issue). They conclude that ACLED comprises a representative set of the more comprehensive data in the released files. The released war logs show that the Afghan insurgency spread rapidly in 2008-2009, that the insurgency is moving out of its traditional Pashtun heartlands, and remains mostly rural in location. Hotspot and cluster analysis identifies the key locations of the current war, which indicate that it is relocating to new provinces in Afghanistan while intensifying in the eastern border regions and in the south.

Boomerang: Opinion versus action in the radicalization of Abu-Mulal al-Balawi

Humam Khalil Abu-Mulal al-Balawi, recruited by Jordanian intelligence as a double agent to gather information on high-profile Taliban leaders, blew himself up on 30 December 2009, in Khost province of Afghanistan. He killed seven CIA agents and one Jordanian agent. We distinguish two phases in al-Balawi's trajectory to violence: radicalization of opinion during his life in Jordan working as a physician from 2002 to 2009, and radicalization of action in Pakistan between March and December 2009. Mechanisms of radicalization, including personal and group grievances and “slippery-slope” increments of commitment, can make sense of al-Balawi's radicalization of opinion, but his turn to violent action requires consideration of his Internet identity as a warrior, Abu Dujana. In our interpretation, his radicalization in action depended on the means and opportunity offered by Jordanian intelligence and the CIA.

Targeting accuracy and impact of a community-identified waiver card scheme for primary care user fees in Afghanistan.

BackgroundUser fees are a known common barrier to using health services, particularly among the poor. When fees are present, many facilities have waiver systems for poor patients to exempt them from paying. Targeting waivers to patients who need them most has been a challenge, especially in fragile states, where relevant data are limited and trust in institutions is low.MethodsCommunity-based targeting of vulnerable households was piloted in Afghanistan and evaluated for its feasibility, accuracy and effect on care-seeking. Waiver cards were distributed to very poor and female-headed households in catchment areas of 26 facilities in 10 provinces of Afghanistan in 2005 as one component of a larger health financing study. Households were nominated by community leaders using general guidelines to support 15% of the poorest members. In most cases, waiver cards were pro-actively distributed to them. Targeting accuracy, perceptions, as well the cards' effects on utilization were evaluated in 2007 through household surveys, health facility data, and in-depth interviews and focus group discussions with facility staff and community leaders.ResultsThe waiver system was implemented quickly at all but one facility charging fees. Facility staff and community leaders reported favorable perceptions of implementation and targeting accuracy.However, an analysis of the asset index of beneficiaries indicated that although targeting was progressive, significant leakage and high levels of under-coverage occurred; 42% of cards were used by people in the wealthiest three quintiles, and only 19% of people in the poorest quintile received a card. Households with waiver cards reported higher rates of care-seeking for recent illnesses compared to those without cards (p = 0.02).ConclusionsCommunity identification of beneficiaries is feasible in a fragile state. Several recommendations are discussed to improve targeting accuracy of a waiver card system in the future, in light of this research and other international experiences.

Learning of Brahui Language in Balochistan.

Brahui a North Proto Dravidian (NPD) language spoken about 2000 km far from other Sourth Dravidian languages (SPD) in South India i.e. Tamil, Talgu, Malyalam, Kanada, Gondi etc and Central Proto Dravidian (CPD) languages in the Central India i.e. Karukh and Malto by about two million people. It is spoken in the central parts of Balochistan, interior Sindh province in Pakistan and in the Sistan o Balochistan province of Iran, Helmund and Nimroz provinces of Afghanistan, Gulf States, and also there are few families have still preserved. Brahui in Mari province of Turkmenistan. In compare with the other nonliterary tribal dialects of Dravidian languages Brahui is enjoying a worth mentioning literary status in Balochistan-Pakistan. The past history of Brahui language is witnessed that it has been used only as an oral language till post-colonial period in Balochistan. There was no tradition of using Brahui as medium of instruction or in writing, although some works in Brahui had appeared before then, the Brahui literary movement started in the reign of Khan Naseer Khan in the 18th century but a standard literary movement started only after the 1950 when some newspapers including “Muhalim Quetta”, “Balochi Karachi” started publishing in Brahui besides Balochi in Pakistan. While weekly “Elum” Mastung a Brahui-Urdu newspaper was a revolutionary addition in the history of Brahui journalism and learning.

FDA: Flush Certain Unused Medications

military-specific curricula such as trauma training and cold-weather medicine, which would be open to all medical students at that university,” said Harrison. Such exposure could be particularly important in this country. “In the turbulence of Afghanistan, any physician might find themselves called to heal the victims of war,” said CDR Kenneth Lankin, MC, USN, who is former liaison to the Afghan Ministry of Public Health. “The medical school will provide a long-term source of highly trained medical officers to care for the Afghan National Security Forces and their families.” “Students want to be involved in providing care and security to people in such a war-torn society,” said LCDR Sunny Ramchandani, MC, USN, who helped establish the medical school’s curriculum. Students were chosen from all provinces of Afghanistan, and some will be sent to the Afghan National Army Regional Hospitals in their home provinces for much of their clinical training after completing their coursework. “On graduation, every effort will be made to assign the doctors to duty stations close to their home provinces,” said retired COL Gary Davis, MC, USA, who has been contracted by the US military and is the students’ medical mentor. “This will ensure that even the remote regions will have well-trained physicians to provide state-of-the-art medical care for the soldiers and their dependants.”

Trends in the quality of health care for children aged less than 5 years in Afghanistan, 2004–2006

To study trends in the quality of the health care provided to children aged less than 5 years in Afghanistan between 2004 and 2006. In particular, to determine the effect on such quality of a basic package of health services (BPHS), including Integrated Management of Childhood Illness (IMCI), introduced in 2003. In each year of the study, 500-600 health facilities providing the BPHS were selected by stratified random sampling in 29 provinces of Afghanistan. We observed consultations for children aged less than 5 years, interviewed their caretakers, interviewed health-care providers and measured adherence to case management standards for assessment and counselling in a random sample. The quality of the assessment and counselling provided to sick children aged less than 5 years improved significantly between 2004 and 2006. A 43.4% increase in the assessment index and a 28.7% increase in the counselling index (P < 0.001) were noted. Assessment quality improved significantly every year and was statistically associated with certain characteristics of the provider (being a doctor, having a higher knowledge score, being trained in IMCI, being part of a "contracting-in" mechanism and providing a longer consultation time) and the child (being younger and having a female caretaker). Counselling quality was also significantly associated with these characteristics, except for provider cadre and child age. The presence of clinical guidelines and the frequency of supervision were significantly associated with improved quality scores in 2006 (P < 0.05 and < 0.01, respectively). Quality of care improved over the study period, but performance remained suboptimal in some areas. Continued investments in Afghanistan's health system capacity are needed.

An experiment with community health funds in Afghanistan

As Afghanistan rebuilds its health system, it faces key challenges in financing health services. To reduce dependence on donor funds, it is important to develop sustainable local financing mechanisms. A second challenge is to reduce high levels of out-of-pocket payments. Community-based health insurance (CBHI) schemes offer the possibility of raising revenues from communities and at the same time providing financial protection. This paper describes the performance of one type of CBHI scheme, the Community Health Fund (CHF), which was piloted for the first time in five provinces of Afghanistan between June 2005 and October 2006. The performance of the CHF programme demonstrates that complex community-based health financing schemes can be implemented in post-conflict settings like Afghanistan, except in areas of high insecurity. The funds raised from the community, via premiums and user fees, enabled the pilot facilities to overcome temporary shortages of drugs and supplies, and to conduct outreach services via mobile clinics. However, enrolment and cost-recovery were modest. The median enrolment rate for premium-paying households was 6% of eligible households in the catchment areas of the clinics. Cost recovery rates ranged up to 16% of total operating costs and 32% of non-salary operating costs. No evidence of reduced out-of-pocket health expenditures was observed at the community level, though CHF members had markedly higher utilization of health services. The main reasons among non-members for not enrolling were being unaware of the programme; high premiums; and perceived low quality of services at the CHF clinics. The performance of Afghanistan's CHF was similar to other CHF-type programmes operating at the primary care level internationally. The solution to building local capacity to finance health services lies in a combination of financing sources rather than any single mechanism. In this context, it is critical that international assistance for Afghanistan's health sector continues.

Stabilising Afghanistan

This article comprises two parts: the first in which the author examines the ramifications of the process of stabilising Afghanistan and the second in which he discusses a possible role for the Russia, India and China (RIC) trilateral. The author cites the results of a survey conducted in all thirty-four provinces of Afghanistan, which mainly concerns the attitude of the people and the national mood in 2004 and 2008. The results revealed very low levels of confidence. The crux of the problem was that the war cannot be won, nor the Afghan situation addressed by the military approach. The situation is extremely complex and tense mainly because of the lack of strategic coherence within the West and their attempt to promote a Western set-up in Afghanistan without heed to, or respect for, the Afghan condition. The focus has been only on capturing the Al-Qaeda through Operation Enduring Freedom. The role of Pakistan was also quite complex and the question was whether it should be seen as part of the problem or part of the solution. The American’s Afghan policy was insensitive to the geopolitical complexity in the region. Since all three countries were affected by the situation in Afghanistan, stability in this area was in the interests of all. It was necessary, therefore, to make the trilateral more relevant and the election in September 2009 provided a good occasion to look for a common agenda and adopt a proactive stance. The RIC could encourage the exploration of a new political set-up in Afghanistan by taking into account its national conditions. They could also stress a leading role for the United Nations and explore a regional approach, whereby the various organisations in the region could be interconnected to explore solutions.

MS04 PERIOPERATIVE OUTCOMES FROM ADF OPERATIONS IN AFGHANISTAN

Background: Surgical audit is a requirement of the Royal Australasian College of Surgeons (RACS) and a normal part of surgical practice. Peri‐operative audit on deployed operations has recently been introduced into the Australian Defence Force (ADF). From 2008 three Australian surgical teams have deployed to Uruzgan province in Afghanistan to provide resuscitative surgical capability within a Dutch NATO forward hospital facility. During this time a trial of a computer based audit programme ADF SurgAssist was undertaken.Methods: All patients undergoing surgery by the Australian surgical team were included. Data was collected prospectively and entered onto a computer based audit system. Data fields included the Minimum Data Set recommended by the RACS, modified to the battlefield environment.Results: (Data from the 3rd rotation will included but is not yet available). A total of 199 operative procedures were undertaken over a discontinuous 12 week period. The majority of cases (&gt;90%) reflected emergency or subsequent management of conflict related trauma. The most common procedure performed was exploration and debridement following explosive or gunshot injury followed by delayed closure or grafting. 11% required orthopaedic fixation. Australian personnel constituted 11% of all operations performed. Paediatric (&lt;16 years) cases accounted for 31%. Follow‐up information is limited but three in‐hospital deaths were reported.Conclusion: Whilst still under development, ADF SurgAssist has demonstrated its utility in the battlefield environment. This is the first time verifiable peri‐operative outcome data has been obtained during ADF operations and represents the ADF's ongoing commitment to best surgical practice.

Enhancing the Footprint: Stakeholders in Afghan Reconstruction

Afghanistan is so clearly demonstrating, one reconstructs during conflict and stabilization, not after it. Reconstruction is in many ways the essential process that bridges conflict and stabilization. (1) The necessities of reconstruction have frequently drawn the International Security Assistance Force (ISAF) into activities that go well beyond its originally intended mission of providing direct security. Examples include contributing security sector reform such as restoring the rule of law or training the national police and army; delivering essential services such as health care, education, or food; and supporting the functioning of the Afghan authorities. Although most military forces would readily agree that they are not the appropriate actors be performing nonsecurity-related tasks within the traditional humanitarian domain, in many areas such as the southern Afghan provinces of Helmand, Zabul, and Uruzgan, tenuous security conditions prevent humanitarian organizations from establishing presence. In some instances these organizations are deliberately targeted by insurgent groups in an effort prevent them from gaining foothold or becoming effective in assisting the local populace. (2) In such situations, the debate on specific domains (3) becomes less relevant, and military involvement in nonmilitary activities is necessary provide temporary gap and gain momentum for reaching the primary military goal: the creation of stability. (4) Based on his deployment as commander of the Australian Reconstruction Task Force in Uruzgan, Lieutenant Colonel Mick Ryan stresses: Consultation with local officials and other interested parties will be critical aspect .... It is worth establishing formal mechanism, involving all stakeholders, facilitate community and government consultation. This interaction should include regular meetings with officials and local inhabitants work out the details of individual projects, ensuring that what will be delivered is what the locals need. (5) The issue of participation by local stakeholders in ISAF's stability and reconstruction activities will be the main focus of this article. As the Provincial Reconstruction Teams (PRTs) are typically tasked to cover reconstruction within ISAF, they form the basis of this analysis. (6) Since other ISAF units are also confronted with local participation, however, their experiences are lesser extent included. This article's objectives are threefold. First, explain why participation of local stakeholders is essential for the overall success of the ISAF mission. Second, identify the challenges ISAF encounters in local participation. Third, formulate measures improve future participation. Local Participation Reconstruction is fluid process, where social relations and the meaning of institutions are renegotiated while people carefully probe their room for maneuver, waiting see if the conditions of relative peace will hold. (7) It is process driven by local actors: residents, government employees, organizations, and businesses; reestablishing relations; and reconfiguring hierarchies. Within this context, experts distinguish four related areas of meaning regarding participation, namely: (1) participation as right be involved in decisionmaking, (2) participation as autonomous action, (3) participation as development based on local knowledge, and (4) participation as transfer of power. (8) These four elements seem merge in the World Bank's definition of participation as a process through which stakeholders influence and share control over development initiatives and the decisions and resources which affect them. (9) In reality, the extent which local stakeholders do influence and share control over areas that affect them varies between almost none full participation, as illustrated in Figure 1, an example of different types of participation by farmers in an agricultural project. …

COIN Machine: The British Military in Afghanistan

This article assesses the British military effort in Afghanistan looking at three key elements in the campaign: strategy, military operations, and the inter-agency “Comprehensive Approach.” We start by recognising the scale of the challenge that has faced the British: of all the provinces in Afghanistan, Helmand is the toughest to stabilize and secure. We then examine the evolution of all three elements above and find significant improvements in each: a flawed strategy has been corrected; the military have received more resources and become significantly better at COIN; and there is significant progress in the development of the inter-agency approach. In short, what the Americans will find in Helmand is a British COIN machine; a little creaky perhaps, but one that is fit for purpose and getting the job done. We briefly conclude on the prospects and the key to success: namely the development of a more coherent international strategy that accommodates the challenges posed by both Afghanistan and Pakistan.

Improving Maternal and Child Health in Difficult Environments: The Case For “Cross-Border” Health Care

The evidence base on organising, delivering, and paying for effective and equitable health services in any resource-constrained setting is very weak [1]. To make health service delivery work in difficult environments, such as Badakhshan province in Afghanistan, the Northern Areas of Pakistan, and Gorno-Badakhshan province in Tajikistan, substantial challenges must be addressed because each has to overcome one or more “traps” of bad governance, emerging from civil war, and/or being landlocked [2]. To improve maternal and child health (MCH), emphasis must be given to strengthening health systems, increasing access to information and care, and addressing the related community and development issues [3]. In the high mountainous areas of Central Asia, the successor states of the Russian and British empires govern communities that are often forgotten and frequently unserved [4]. In some measure, the health status of these communities, especially that of the women and children living in the contiguous border areas of three states (Afghanistan, Pakistan, and Tajikistan) reflects the challenges, successes, and failures of these states. Although the communities in these adjacent geographical areas share a common ethnicity, religion, and culture, MCH indicators vary widely along with the capacities and efforts of governmental and non-governmental actors to reduce the disparities. In the rural province of Afghan Badakhshan, a remote region with minimal infrastructure and few modern health services, Linda Bartlett and others recently carried out a reproductive age mortality survey [5]. Reported in 2005, this survey found the highest maternal mortality ratio ever documented (6,507 per 100,000 live births) for a three-year time period (April 1999 through March 2002), and a very high infant mortality rate (217 per 1,000 live births) [5]. Gorno-Badakhshan Autonomous Oblast sits on the other side of the Oxus (Amu Darya, Panji) River in the newly independent Republic of Tajikistan. Here, the Soviet health system contributed to a relatively low maternal mortality ratio (54 per 100,000 live births) and infant mortality rate (28 per 1,000 live births), even as late as 1994. Recent surveys in the Oblast suggest that the new republic's health system has not been able to maintain or improve the indicators achieved during the Soviet period. In the Northern Areas of Pakistan, a disputed territory but contiguous with the other regions, local government institutions have traditionally been very weak. However, important improvements in maternal and child health indicators, including a substantial reduction in the maternal mortality ratio (from 550 to 68 per 100,000 live births) and infant mortality rate (from 158 to 31 per 1,000 live births) have been observed over the last 20 years. While under-reporting of maternal, infant, and especially neonatal deaths is a global problem, and variations in data collection methods challenge the comparability of the measures across the three regions, the substantial differences strongly suggest true distinctions that should be examined to determine why women and infants in the Northern Areas and Gorno-Badakhshan have markedly lower risk of death. Summary Points Health indicators, including levels of maternal and infant mortality, are very different in adjacent geographical border areas of Afghanistan, Pakistan, and Tajikistan. These differences reflect the combined and complex interplay of elements within the different health systems, as well as political, economic, social, and cultural factors. Reducing maternal and child mortality requires focus and balance in all of these dimensions and can best be achieved through service interventions underpinned by general development. A policy promoting “cross-border” health programmes could immediately make available existing resources that could contribute to reducing maternal and child mortality in all three geographical locations.