80 Lack of infrastructure The lack of infrastructure in Afghanistan is manifested in many ways. A poor road network and near complete absence of railways makes some rural areas inaccessible during heavy winter snowfalls. Only 6% of Afghans have access to reliable electricity sources. Only 30% of house- holds outside of cities have access to safe drinking water [3]. There are 2 landline telephones per 1,000 people, with half of these phones in Kabul [17]. Improvement of the health care system will require investment in transportation, electricity, safe water, and communications. Health care quality and resources available vary widely from urban to rural areas. Hospitals outside of Kabul have a difficult time providing anything more than rudimentary care. For instance, when the International Council on Security and Development surveyed Mirwais Hospital, a regional hospital in Kandahar City, it was found to have 0.15 beds per 1,000 people compared to Kabul’s 9.1 beds per 1,000 people. Mirwais Hospital does not have heat, thermometers, or record keeping. Electricity is intermittent and running water is usually dirty. It has one X-ray machine from the 1960s. Medications for hospitalized patients must be purchased from an outside pharmacy by family members and brought to the hospital. This situation is common through- out the country [20]. If there is medical equipment, most health care workers are not properly trained to operate or maintain it. Medical laboratories lack supplies and personnel. While primary care remains the appropriate focus of Afghani- stan’s health care system, hospitals need to be revitalized, especially for the practice of emergency medicine. Economic instability Another issue is economic instability. Nearly 70% of Afghans live in extreme poverty with a 32% unemployment rate. Health care funding mainly comes from outside sources such as the European Commission, World Bank, and USAID [3]. While external funding is key, domestic support of health care must increase. External funding has unpredictable availability, frequent policy shifts, and the potential to end without warning [16]. Currently, domestic health care spending is a low priority with per capita spending on health care at 0.6% of the country’s gross domestic product (GDP). Improvement in the economy, viable internal funding sources, and more spending by the Afghan government will improve access and affordability of health care. Communication and coordination The Ministry of Public Health contracts with NGOs for the majority of health care in Afghanistan. Although the Int J Emerg Med (2009) 2:77–82 Ministry and NGOs have improved communication, lack of coordination on a provincial and district level results in inefficient and, at times, duplicated services. The ANA, ANP, and Ministry of Public Health have developed separate but redundant health care facilities to serve specific segments of the population. Lastly, a large number of Afghans use unregulated private sector health care. Inte- gration and coordination among NGOs, the Ministry of Public Health, and various sectors of the Afghan govern- ment will be required to create a sustainable health care system for the entire country [3, 16]. Public health infrastructure A discussion of health care access improvements is not complete without attention to basic needs. While basic health care is important, the lack of food, clean water, and shelter must also be addressed to improve community health. A survey of families regarding the health and nutrition of children under age 5 showed 59% of respond- ents experienced a shortage of basic material needs for at least 1 year [21]. Chronic malnutrition is rampant with 40% of Afghanistan’s children underweight and 54% with stunted growth [16]. Due to the recent years of drought and poor food security, nearly 5 million people depend on food assistance from the UN and other relief organizations [3]. Ensuring the population of Afghanistan has adequate food, water, and shelter must keep pace with improving health care access. Health care workforce Another obstacle for Afghanistan’s health care system is the lack of qualified health care workers. During the Taliban years, many health care workers were killed or fled the country. The “brain drain” on Afghanistan left few health care workers. Of those who remain, medical training is inconsistent because of the lack of standardized training programs [17]. During the 1990s, medical schools were operated according to ethnic and religious rivalry. Conse- quently, medical students were often admitted through nepotism. A survey by the WHO showed 70% of nurses, midwives, and laboratory technicians did not meet minimum knowledge and skills standards when they were tested. The Ministry of Public Health cannot employ those trained by some NGOs because they do not meet the government’s strict requirements. As a result, a nationwide survey indicated a shortage of least 7,000 physicians and 20,000 nurses, midwives, and allied health professionals [3, 22]. Despite the 11,000 medical students enrolled in 6 medical schools and 2,500–3,500 students enrolled in 9 Institutes of Health Sciences, problems with health educa- tion remain. The salary for physicians is too low for a