Int J Emerg Med (2009) 2:77–82 Table 2 Basic Package of Health Services Focus areas Maternal and newborn health Child health and immunizations Nutrition Communicable diseases Mental health Disability Pharmaceutical supply limitations in infrastructure, be cost effective, and give equal access to health care in both rural and urban areas. Focus areas included maternal and newborn health, child health and immunizations, nutrition, communicable dis- eases, mental health, disability, and pharmaceutical supply [13]. The cost of delivering these BPHS was difficult to determine as health care was and still is provided by various groups, including the Afghan government, donors, and NGOs. Initial WHO estimates placed the cost at around US $40 per person to start a rebuilding program in Afghanistan [14]. After careful consideration of the BPHS, several NGOs later estimated the cost of providing these services to 80% of the population at US $4.30–$5.12 per capita [15]. Six years ago only 9% of Afghanistan’s population of 28 million people had basic health coverage. Today nearly 85% of the population has access (within a 2-h walk) to basic health care. The goal for 2010 is 90% [16]. Health care delivery Since the defeat of the Taliban in 2001, medical services in Afghanistan have been provided mostly by NGOs con- tracted through the Ministry of Public Health. Recently, the ANSF have been increasingly involved in providing health care in Afghanistan with the guidance of the US military. Emergency medicine is not yet a recognized or developed specialty in Afghanistan, but improving emergency care systems in the country will most likely improve health outcomes [13]. Full service emergency departments (EDs) exist for US military personnel at Bagram and other NATO military hospitals. While EDs do exist at some district hospitals and community health centers throughout the country, they are staffed by general practitioners with little or no emergency care training. Local emergency depart- ment administrators are not trained to manage EDs. This can be a problem for improving day-to-day operations of the departments. Despite these challenges, some progress has been made in rebuilding the Afghan medical system according to the Center for Disaster and Humanitarian Assistance Medicine, particularly in emergency medicine. Much of this progress has been made in the military sector. Over 2,000 ANA 79 combat medics have been trained in a standardized course adapted from US Army training focusing on combat casualty care. Over 700 ambulance vehicles have been purchased for ANSF use, but whether medics are properly trained to operate and use these vehicles and the appropriate distribution of them remains to be seen. Kabul Medical University has reduced its class sizes to manageable numbers, updated its nursing and medical school curricula, improved technology in teaching laboratories, and devel- oped good relationships with the ANA and Ministry of Public Health. Graduate training programs in various fields exist, but specific training for emergency physicians is still lacking. Currently the plans for emergency services in Afghanistan are limited to the military sector. The focus on civilian health care is on primary care services, but as these improve, the long-term goal is to advance emergency care in the civilian sector as well. Challenges to the development of health care systems in Afghanistan There are many barriers to creating an accessible, effective, and sustainable health care system in Afghanistan. The main challenges of rebuilding Afghanistan’s health care system include a lack of security, lack of infrastructure, economic hardship, poor coordination among government and health care providers, difficult access to health care facilities, unsuitable hospital conditions, and few trained health care workers, especially women. Security The security situation in Afghanistan remains unsafe and unpredictable. There are many threats such as suicide bombers, the widespread narcotics trade, and kidnapping for ransom. Afghanistan has more land mines and impro- vised explosive devices (IEDs) than any other country in the world [17]. In 2007, 45% of Afghanistan’s districts were not accessible to UN missions for extended periods of time due to security constraints and movement restrictions [18]. In addition to general insecurity, health centers and health care workers are targets. More than 50 health care centers have been closed due to violence. In 2004, more than 40 health and reconstruction workers were killed, including 5 who were murdered specifically for being health care workers. Due to this violence, at least 300,000 people lost access to primary care services last year [19]. Lack of security also affects those trying to seek medical care. Utilization of services in secure provinces is three times greater than in areas of active conflict [16]. Improved security is required for continued improvement in Afghani- stan’s emergency health care system.