IntroductionAfghanistan has faced health consequences of war including those due to displacement of populations, breakdown of health and social services, and increased risks of disease transmission for over three decades. Yet it was able to restructure its National Tuberculosis Control Programme (NTP), integrate tuberculosis treatment into primary health care and achieve most of its targets by the year 2011. What were the processes that enabled the programme to achieve its targets? More importantly, what were the underpinning factors that made this success possible? We addressed these important questions through a case study.Case descriptionWe adopted a processes and outcomes framework for this study, which began with examining the change in key programme indicators, followed by backwards tracing of the processes and underlying factors, responsible for this change. Methods included review of the published and grey literature along with in-depth interviews of 15 key informants involved with the care of tuberculosis patients in Afghanistan.Discussion and evaluationTB incidence and mortality per 100,000 decreased from 325 and 92 to 189 and 39 respectively, while case notification and treatment success improved during the decade under study. Efficient programme structures were enabled through high political commitment from the Government, strong leadership from the programme, effective partnership and coordination among stakeholders, and adequate technical and financial support from the development partners.ConclusionsThe NTP Afghanistan is an example that public health programmes can be effectively implemented in fragile states. High political commitment and strong local leadership are essential factors for such programmes. To ensure long-term effectiveness of the NTP, the international support should be withdrawn in a phased manner, coupled with a sequential increase in resources allocated to the NTP by the Government of Afghanistan.

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where appropriate. Shapiro-Wilks tests for normality were used. Wilcoxon and Kruskal-Wallis tests were used for non-parametric continuous variables. Percentages and frequencies are reported. P < .05 was significant.Results: Five hundred thirty-two patients were included-average age 27 years, 99% male, 40% US or coalition forces. Most procedures were performed by medics. We found no association between ISS score and administration of analgesic agents. 71% of patients received analgesic agents (541 total administrations): ketamine 36%, fentanyl 30%, morphine 25%, hydromorphone 4%, acetaminophen 2%, ketorolac 2%, oxycodone <1%, and ibuprofen <1%. Those who received analgesics were more likely to have had a penetrating injury (89% vs 79%, P ¼ .0057) and less likely to have a blast injury (87% vs 80%, P ¼ .0394) or burn injury (84% vs 58%, P ¼ .0372). Fentanyl was more likely to be administered for ISS >15 (P ¼ .016). Ketamine was less likely to be given for suspected brain injury (P ¼ .001). Injuries involving the chest and/or abdomen were more likely to receive an analgesic agent (P ¼ .04). However, there was no association between the analgesic agent given and anatomical location of injuries. Our outcomes through 30 days post-injury were death 4%, receiving on-going treatment 75%, discharged home 17%, and unknown 4%. Those who received analgesics were more likely to be in continued medical care at 30 days post injury (87% vs 72%, P ¼ .03).Conclusions: In our out-of-hospital study in the combat theater, we found no association between injury severity score and administration of analgesia. When injuries were more severe fentanyl was more likely to be given. In addition, those who received analgesics were more likely to have sustained a penetrating injury and require on-going care at 30 days. Ketamine was less likely to be used in patients with brain injury.