The alleviation of global poverty requires transformational change and a deeper understanding of how to empower and inspire those who subsist on less than $3000 a year. Heriot-Watt doctorate, Dr Kevin Schneider, undertook his research in Afghanistan where he examined the work of a life-changing health care initiative. He talks to Kenny Kemp.

A smiling ten-year-old girl sits on a rug in the shade beneath a tree. She wears a white scarf and has a coloured pen in her hand and is writing her name. She is one of eight young female classmates enjoying lessons in a rural community centre and health clinic that is bringing vital services, along with English and computer training, and the empowerment of women in many rural Afghan villages.

Behind the headlines, work is going on to build sustainable communities and bring hope to a region that has known conflict and attrition for far too long. The community centre, supported by private donors and endorsed by the Afghan Ministry of Public Health, serves around 40 villages and all activities, including agricultural demonstrations, health education and computer classes, are coordinated with the sanction of a group of tribal village elders called a shura.

Dr Kevin Schneider, now the Director of the Office of Global Service at Oral Roberts University in Tulsa, is also a leading academic researcher into how to help alleviate poverty. It was through Heriot-Watt University and Edinburgh Business School that he gained his DBA in what is one of the most comprehensive pieces of research on the BoP (base of the pyramid) cohorts.

Abhorrent Health Statistics

Dr Schneider wanted to assess how well these rural community centres in Afghanistan were doing and it became the subject of his thesis: Testing the BoP Impact Assessment Framework Through Assessing the Socio-Economic Impact of a Health Care Venture in Afghanistan.

"Initially what got my attention was the level of poverty in Afghanistan. There are many organisations working in various sectors throughout the country, and I wanted to play a role in the international effort to rebuild the country,’’ he said. “For instance, if you look at the health statistics for Afghanistan prior to 2001, they were abhorrent. There was a seed in my heart that some day I might be able to help them."

Through his connections with the United Nations, Dr Schneider, already armed with a MBA, worked with the Afghan Ministry of Finance in 2003 on a summer internship.

"I really wanted to see how business could help alleviate poverty. So I was looking at aid and development in the country. For me, the need in health care is really gripping. Traditionally, the health statistics in the region were so bad. There was still a lot of need," he said.

There was a great deal of international development going in, rather than charity and aid, which was helping to reconstruct the nation after the rule of the Taliban.

"There was a lot of capacity building for the government, because an internationally recognised government didn’t exist while the Taliban were in power," he said.

It was then that he came across Morning Star Development, a development organisation working in the country. They had a vision for community centres that would empower rural villages through teaching English, computer training, and access to primary health care, explained Dr Schneider.

Morning Star Development became the focus for the Heriot-Watt University research study, and the results pertain to Tangi Saidan health clinic near Kabul, Afghanistan. Until the community and health centre was established the maternal health statistics were "abysmal". There was a one-in-six-to one-in-nine chance of the mother dying in childbirth. Morning Star Development has focused on improving the health for mothers.

The impact has been significant; trained medical staff perform deliveries in a proper delivery room, and there is antenatal care and information on nutrition.

Meeting place for women

Three primary benefits emerged from the study: lower health care costs, stronger relationships and safer health care behaviours. Before, mothers-to-be faced transport costs to Kabul, loss of wages, accommodation and nazrana, which was money for gifts. Now, patients typically walk to the Tangi Saidan health clinic and normally do not miss any work. What emerged was that the centre became a second public meeting place in addition to the mosque.

Because women are not allowed to visit the mosque, there was no central location in the villages surrounding Tangi Saidan where they could meet in public before the clinic was established. Therefore, the health clinic acts as the only public meeting place for women in the Tangi Saidan region.

Through Morning Star Development, there was an opportunity for Dr Schneider to work in Afghanistan prior to beginning his doctoral studies, but it wasn’t the right time and he continued to gain his doctorate. Then in 2010, Dr Schneider encountered the new thinking around BoP and began discussions with Morning Star about whether he could work with them.

"I had to drill down to the area of focus and decided it would be the impact assessment which led to my doctorate with Edinburgh Business School."

Before returning to Afghanistan, Dr Schneider spoke with Heriot-Watt’s authorities to look at the risk-management of conducting research in Afghanistan, which was still a dangerous place for Westerners.

"One of the benefits is that Heriot-Watt has a lot of students from the Middle East and has a reputation as a leading research university, although there had not been a United States citizen doing this kind of field research in such a dangerous area. I’m delighted that they allowed me to do it," he said.

The clinic is seen as a fundamental place in helping women play an important role in their male-dominated tribal society.

“Socially embedding an initiative in a community is important for venture success and requires building on the local market environment. Companies can accomplish this by working with local communities, building relationships and leveraging available human capital. For example, by working with local self-help groups that function on the basis of personal relationships, firms can build upon the one to one interactional market context," recorded Schneider.

“Because the BoP literature provides little information concerning health care in Afghanistan, more detailed knowledge concerning the Afghanistan health care literature was required. For instance, utilisation, quality of care, patient satisfaction and cost are central themes within the Afghanistan health care literature that affect how assessment might be measured."

Dr Schneider spent five weeks in Afghanistan conducting the interviews and running the focus groups. He went out in the field and pays special tribute and thanks to his Afghan assistant and translator who worked with him.

“It was an intensive period in the summer of 2013." Before making the trip, he undertook a literature review of the health care industry in Afghanistan and found that it was very sparse and primarily driven by public government organisations, such as the World Bank, or the World Health Organization.

“But there were a lot of gaps, so it was very, very interesting. There are reports out there but putting it all together was part of my preliminary work," he explained.

Image from Pixabay the 1980s and 1990s, the majority of health care in Afghanistan was provided by NGOs that worked cross-border from Pakistan. There was no central health care policy in Afghanistan, and the delivery of primary health care services was extremely limited and unevenly distributed. The Taliban then took control and dominated the political landscape starting in 1996. As a result of their rule, the Taliban moved Afghanistan backwards politically, economically and culturally.

The successive wars killed over a million Afghans, forced several million people into exile and refugee camps and left almost a million people disabled. The destruction of core institutions and a war-torn economy led to extreme levels of poverty, illiteracy, gender inequality and a degenerated health care system.

This was the situation that the international community encountered in Afghanistan after the Taliban was driven from the country in 2001.

The collaborative work, which included the World Health Organisation, UNICEF, and Afghan Ministry of Public Health resulted in the creation of the Basic Package of Health Services (BPHS), which forms the foundation of public health care policy in Afghanistan In July 2010, foreign ministers and diplomats from 70 countries attended the International conference on Afghanistan in Kabul which noted the peace initiatives of President Hamid Karzai. The communique set out a pledge to secure peace, build a long-term electoral reform to create sustainability and a democratic Afghanistan and work toward the integration of women into all programmes.

Schneider found that while good governance, the rule of law, and human rights form the foundation of the strategy to achieve a stable and prosperous Afghanistan, the public health care system was not specifically covered by the International Communique.

Great strides in maternity care

"There were a few NGOS working from Pakistan and it was such a difficult time under the Taliban. The International Communique has started to build up the health care system which in some ways is working and in other places not effective enough."

Health care was being funded and rebuilt by the public sector. However, a significant private market emerged due to various gaps in the system. Public health care providers include formally established facilities such as hospitals, clinics, pharmacies and laboratories. In addition, many physicians have their own private practices, which may be in a small office or the physician’s home. Nurses, midwives and birth attendants may also practise in the private sector. Traditional healers, such as Mullahs, are even considered part of the private sector.

Primary health services include services such as routine physical examinations, diagnosis and prescription of medication. Basic maternal health services include antenatal care, delivery and postnatal care. Prescription and drug service providers diagnose conditions, prescribe medications and provide the drugs.

"Compared to having almost no previous access to health care, the public health care sector made great strides toward meeting the needs of women and children. However, on the quality of health care there were a great deal of reports of complaints about doctors not showing up or medicines that were unavailable and poor levels of care."

“Some areas were providing better health care than others, but in general due to the significance of the emergence of the private healthcare system there are gaps in the provision for those at the BoP. For more serious treatments, such as cancer or heart treatment many sick people had to fly to Pakistan or India and few could afford such treatment."

"The public health care system is ‘free’. It is not that people don’t have money. There are other countries where people may face a more challenging environment compared to Afghanistan. The poverty is acute but most people have access to agricultural land, and the extended family structure often pitches in to find the money to pay the fees."

There are costs associated with travel and interesting cultural dimension called nazrana. This term refers to giving a gift, and in this context it is used to give money to ensure you receive more than the basic health care, although it is not viewed as a bribe. This collective society still works in Afghanistan.

Dr Schneider started with an MSc in strategic planning before proceeding with the DBA. He found it rigorous and relevant and "outstanding" working with Dr John Temperley, as his supervisor, and Professor Neil Kay, his academic mentor.

"I wanted to continue to teach as I was working on my doctoral studies. The Heriot-Watt programme was the best one I could find that offered a distance programme in strategic planning that I could work on and still keep up my teaching. I loved the programme. I like to tell people we live in a global world. I can teach in the United States, work on my doctoral studies through the university in Edinburgh in Scotland and do my original research in Afghanistan."

Since then Dr Schneider has been appointed Executive Director of the Office of Global Service at Oral Roberts University, in Tulsa, which includes an international focus on examining global poverty.

“It was difficult to leave the classroom and my research has been put on the shelf for the moment but the new position provides an exciting opportunity to lead transformational projects."

Dr Kevin Schneider is the Director of the Office of Global Service at Oral Roberts University, Tulsa, in Oklahoma, United States.

Kenny Kemp is an award-winning journalist and business writer. He is currently writing a history of Clyde Blowers Capital, one of Scotland’s leading private equity firms, which specialises in mission-critical engineering.