Afghanistan is one of the most fragile and conflict-affected countries in the world. It has experienced almost uninterrupted conflict for the last thirty years, with the present conflict now lasting over a decade. With no history of a functioning healthcare system, the creation of the Basic Package of Health Services (BPHS) in 2003 was a response to Afghanistan’s dire health needs following decades of war. Its objective was to provide a bare minimum of essential health services, which could be scaled up rapidly through contracting mechanisms with Non-Governmental Organisations (NGOs). The central thesis of this article is that, despite the good intentions of the BPHS, not enough has been done to overcome the barriers to accessing its services. This analysis, enabled through a review of the existing literature, identifies and categorises these barriers into the three access dimensions of: acceptability, affordability and availability. As each of these is explored individually, analysis will show the extent to which these barriers to access are a critical issue, consider the underlying reasons for their existence and evaluate the efforts to overcome these barriers. Understanding these barriers and the policies that have been implemented to address them is critical to the future of health system strengthening in Afghanistan.

(J Med Genet 1993;30:369-75)

1. Following the finding of high levels of oestrogen receptor proteins in pancreatic carcinoma tissue, two enzymes involved in sex-steroid biosynthetic pathways, aromatase and 5 alpha-reductase, have been measured. 2. Activities of aromatase, which converts testosterone into oestradiol, comparable with those found in pre-menopausal uterus (P less than 0.5) were found in all seven samples of pancreatic carcinoma tissue, and in a pooled sample of foetal pancreas. Measurable but significantly lower activities (P less than 0.001) of aromatase were found in seven specimens of normal pancreas. 3. 5 alpha-Reductase activity, which converts testosterone into the more potent androgen 5 alpha-dihydrotestosterone, was found in malignant pancreatic tissue at approximately half the level found in prostatic tissue (P less than 0.01) and at almost twice the levels found in either normal adult or pooled foetal pancreatic tissue (P less than 0.01). 4. These findings suggest that sex steroids are involved in foetal and adult pancreatic physiology. 5. Since these enzyme pathways are present in pancreatic carcinoma at greater levels than those in normal adult pancreas, it is possible that agents known to interfere with steroid metabolism could be of value in the treatment of this tumour.