78 Background lie ahead as efforts to improve the country’s health care system continue. Table 1 Health indices in Afghanistan Afghanistan borders Pakistan, Iran, China, and the Central Asian Republics of Turkmenistan, Uzbekistan, and Tajiki- stan (Fig. 1) [1]. Following the conclusion of the 10-year invasion and war with the Soviet Union, which lasted from 1979 to 1989, Western interest and support faded. Internal factions fighting for control destroyed much of Afghani- stan’s infrastructure, including what limited health care facilities existed. An ineffective government under the Taliban regime also contributed to an ineffective health care system [2]. Since the Taliban were deposed in 2001 by the US invasion, health care delivery has been mainly through NGOs. Afghanistan has some of the worst health indices in the world (Table 1). Afghanistan ranked 173 out of 178 in the United Nations Human Development Index in 2004 [3]. Many infectious diseases such as acute respiratory infec- tions, diarrheal diseases, measles, and malaria contribute to the burden of disease. Malnutrition, physical trauma, psychological trauma, and human rights abuses are also significant problems in the country [4, 5]. Since 2001, Afghanistan’s health status has improved slowly, but much still needs to be done [6]. Emergency medicine in Afghanistan has not been developed or Fig. 1 Afghanistan and its neighbors Int J Emerg Med (2009) 2:77–82 2000 2006 Maternal mortality (per 100,000 live births) 1800 Infant mortality (per 1,000 live births) 165 165 Under age 5 mortality (per 1,000 live births) 257 257 Life expectancy 41 years 42 years Women with antenatal care 4.6% 32.2% Skilled attendant delivery 6% 18.9% recognized as a specialty. Outside US military and NATO hospitals, reliable emergency services are not available for the public [7]. Very poor roads and lack of vehicles make ambulance access difficult for civilians. Steps taken thus far to rebuild the health care system in Afghanistan The Afghan National Security Forces (ANSF), comprised of the Afghan National Army (ANA) and the Afghan National Police (ANP), provide some health care, much of which is tertiary care; however, continued international support for the ANSF is crucial for its maintenance. Most of the tertiary services provided by the ANSF are in Kabul, with regional hospitals in Kandahar, Gardez, Mazar-e Sharif, and Herat. Currently 82% of the entire population lives in districts where primary care services are provided by NGOs under contracts with the Ministry of Public Health of Afghanistan or through grants [8]. Much money and effort has been put into establishing tertiary care hospitals, but a coordinated health care infrastructure has not yet been developed in this country [9]. Consequently, many are still living without access to primary health care [10]. An estimated 70% of medical programs in the country have been implemented by aid organizations [11]. Although these organizations are somewhat successful, access to health care remains a problem [8]. There is a major shortage of a health care workforce in Afghanistan. World Health Organization data show that there are only 6,000 physicians and 14,000 nurses for a population of 28 million people [12]. Basic Package of Health Services In March 2002, the Afghan Ministry of Public Health developed the Basic Package of Health Services (BPHS) as a guide for the health services that the Afghan government would commit to provide for all Afghan citizens (Table 2). Services were identified that would have the greatest impact on major health problems, be achievable given the