Rebuilding Health Systems in Afghanistan, and Providing Health Services in a Fragile Context

Department of Health and Human Services

Nadera Burhani, MD,MPH,MPPM, IHR09/12/2016

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Outline Country Profile Background/ Rationale Achievements toward MGD Stakeholders Involved Impact of Best Practice National Emergency Response for Public Health Hazards Surveillance system /DEWSLessons LearnedChallenges

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Country profile

• A landlocked and mountainous• Population : 32 million, 42nd most populous country• Strategically located between Asia, Europe and the

Middle East-• Has been fought over by Alexander the Great, the

Persian emperor Nadir Shah, the British, the Soviets, Afghan warlords and recently the Taliban and the NATO-led forces.• Low income with a fragile socio-economic status, and

political instability 3

Security Situation

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Security (threat) level

Population (2015 , CEO) 32million (51% M , 49% F )

Population Growth Rate (average annual %) 2.03

Life expectancy at birth (female and male, years) 62/64 (AMS 2010)

TFR 5.2 (AMS 2010)

Literacy rate 45% men and 17% women (NRVA 2012)

Per capita GDP/ Per capita health spending US$634 ( CSO ) / US$55

GDP growth 4.2%

Rural Population 74%

Category Total Number

No. of Population per health worker

category

Physician 8685 1: 3146

Nurse 6749 1: 3778

Midwives 3484 1: 7319

In general, Afghanistan have 7.41 Health

workers/10.000 Population

Socio Demographic Profile

The Ministry Of Public Health (MOPH)

Vision: All citizens reach their full potential in health contributing to peace, stability and sustainable development in Afghanistan. Values: Equity, Integrity, Right to Health, Accountability and TrustMission: To improve the health and nutritional status of the people of Afghanistan in an equitable and sustainable manner through provision of quality health services ,advocating for the development of healthy environments and living conditions, promoting the healthy lifestyles, and ensuring universal health coverage.

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Background/ Rationale

• To address the highest priority health problems• Expansion health services coverage to remote and

underserved areas • Provide and standardize package of basic and core

services delivery• Joint platform to support critical health priorities &

allocation of resources in a coordinated fashion among stakeholders

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Background/ Rationale….:

• The BPHS provides a comprehensive list of services • Maternal and newborn health; • Child health and immunization; • Public nutrition; • Communicable disease control; • Mental health care; and disability referrals.• Supply of essential drugs offered at all BPHS health facilities.

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Process • BPHS package was developed in 2003 for making:a) Maximum use of limited resourcesb) For equitable, accessible, acceptable and quality healthcarec) Improve access in underserved rural areas• Contracted out health services to a network of local and

international NGOs• Currently being offered nationwide• Complemented by essential package of hospital services

(EPHS)

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…Process/linkage

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Stakeholders Involved

• Ministry of Public Health• Government Institutions (other ministries) • UN Agencies• Donor community (USAID, EU, WB, ADB)• National and International NGOs• Private sector (public-private partnership• Community

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IndicatorHealth Policy 2012-2020

Baseline 2002

Target 2015

Target 2020

Achievement 2010 (AMS)

Maternal Mortality Ratio 1600 270 200 327/100000 Live Birth

Proportion of Skilled Births Attended

14.3% 50% 75% 34%

Total Fertility Rate (No. of live Births per woman)

6.6 4.7 3.1 5.1

Proportion of women receiving professional ANC

4.3% 25% 50% 68%

Contraceptive Prevalence Rate 4% 15% 30% 20%

Infant Mortality Rate 165 60 45 77/1000 Live Birth

Child under 5 Mortality Rate 192 85 65 97/1000 Live Birth

Afghanistan MDG (4,5,6)

1. BPHS, EPHS and Increasing & upgrading of HFs2. Bonded CME program with opportunity for further

career growth through bridging program and direct entry into a bachelor program

3. Establishment of Community based Family Health Houses staffed with community midwives and supported by MHT for outreach to rural areas and referral linkages

4. Initiating Maternal Death Surveillance & Response

5. Program to mobilize socio-cultural and institutional structures for Family planning • Partnership with Religious leaders , MoHRA ,

Media , Civil societies6. Expanding access to CEmONC , BEmONC services

• Capacity building • Equipment

7. Expansion of Maternity Waiting Homes

Innovation and High Impact Interventions

Steps taken by MOPH

Strengthen the health system:• Develop polices and guidelines that support best practices and create

an enabling environment: o Basic Package of Health Services (BPHS-2010) o Essential Package of Hospital Services (EPHS-2010), National RH

Strategy, National Midwifery Education Policy etcIncrease access to and use of health services:• Support education and deployment of large numbers of qualified

and competent midwives to work in underserved areas• Scale up and strengthen community-based health care• Generate demand for services and expand behavior change

communication and community mobilization activities• Develop a community health nursing education program

…Steps taken by MOPH

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Standardize and Improve Quality of Maternal and RH services:• Strengthen BEmONC and CEmONC services• Establish National Midwifery and Nursing Education

Accreditation Board from 340 in 2003 to 2813 in 2013• Utilize performance standards for primary health providers

and improve supportive supervision• Strengthen in-service training with competency-based

learning materials.• Initiatives like Maternity Waiting Homes in 6 Provinces (82)

Family Health House in 3 provinces ,PPH project male involvement, Fistula repairing center.

Only 1 in 3 births were attended by SBA. (AMS2010)

SURVEY 2003 MICS 2005 NRVA 2006 AHS NRVA 2008 2010 AMS 2011 MICS

Estimate (%) 6.0 8.4 18.9 24 34 38.6

Maternal Mortality RatioHow Does Afghanistan Compare ?

Deaths per 100,000 live births

Data source: AMS 2010; Streatfield et al. (2011) for Bangladesh 2010; and DHS Survey reports for Nepal and Pakistan

Under (5) MortalityHow Does Afghanistan Compare ?

Deaths per 1000 live births under (5)

Contraceptive UseHow Does Afghanistan Compare ?

% of Married Women who are using any modern method

Total Fertility RateHow Does Afghanistan Compare ?

TFR for Women age 15-49

Emergencies responses and preparedness

• Afghanistan is a disaster prone country with numerous recurrent natural calamities of different scales• Ongoing conflict and political instability reduces

the preparedness and coping capacity of the state and communities up to 50%.• The Afghan health system heavily relied on

international humanitarian assistance for resources and medical expertise

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National All Hazards Emergency Response Plan for Health Purpose: To ensure organized response to health emergencies • Maximize resource utilization and optimize the responses

effectiveness and efficiency

Goal: To ensure continuity of essential lifesaving health care services in the event of emergency for affected population.

Objectives: To prevent and reduce avoidable mortality and morbidity through provision of lifesaving health services • To Enhance coordination among relevant stakeholders during

emergency • To address public health risk with focus on communicable

disease among affected Population 25

According to NERPH..

• Managing of casualties due to societal and or natural hazards (first aid, triage, transport, pre-hospital care, in-patient care, out-patient care)• Controlling of communicable diseases through surveillance,

tracking, treatment, prophylaxis, isolation and quarantine• Maintaining continuity of delivery of critical and essential

services in humanitarian setting (mental health, environmental health, child and maternal health services)• Managing of the dead bodies and missing people• Management of information • Ensuring effective intra and inter-sectoral collaboration and

coordination 26

The Emergency Management National Decision Makers

State Minister for Disaster Management and Humanitarian Affairs

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CEO/State Minister

• Incident commander

ANDMA • intersectoral coordination

MOPH/ Incident

commander

DREHC -committee

Dec

isio

ns ,

reco

mm

enda

tion

s

DISASTER RESPONSE EMERGENCY HEALTH COMMITTEE

Chain of command & incident management system:At the central and provincial levels

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Incident commander

relevant department

Central DEWS

DEWS

Media

MOPH PLO

PHD

Facility

Community

Incident commander

Response Information mgt

Information

DEWS

Technical ops

Planning

Curative

Preventive

Health promotion

Core Services

Logistics

Staff Safety

Resource mob

HR

Admin Fin Proc

coordination Comms

Vulnerability

Increased conflict

Displacement

Impact on health

Reduced Coping Capacity

AFGHANISTAN CONTEXT

Geographical implications of

dynamic conflict:

Intensity &Expansion

Direct health effect

on population in conflict

area

Effect on capacity/function of health services.

- Direct damage- Disruption of

supply chain or lack of staff

• Humanitarian access - conflict

• Disruption of basic services, and affects on health

KEY DRIVERS OF CRISIS- 2016-17

> 5 million

people in need of

basic health

services

over 450,000

IDPs , and expected 600,000 returnee by end of

2016

Cultural barriers;

lack of FHWs

particularly in remote

areas

Context:Population displacementInadequate shelter,Insufficient & unsafe water/food and poor sanitation

Risk factors associated

with disease outbreaks

GAPS & CHALLENGES

• Low coping capacity of local communities and public institutions• Inadequate health workers in the conflict areas • Interrupted chain of supply: Essential Medicines and medical

consumables • No institutionalized ER with no regular resource allocation to EPR.• No decentralized EPR planning at the district/village level.• Unpredictable funding pledges to extended emergencies in the

region• Increasing number of (IDPs) and the influx of returnees from

Pakistan • Insecurity and limited access to emergency locations in high-risk

provinces • Damage to the HFs hampers delivery of essential health care

Disease surveillance/Diseases Early Warning System (DEWS)

A sentinel site based surveillance system with both,• Indicator-based surveillance for weekly reporting of 15 priority

infectious diseases including morbidity and mortality

• Event-based reporting of unusual events and suspected outbreaks of any diseases, chemical, radio-nuclear, food borne, emerging diseases (MERS- COV, EVD, Influenza and other potential PHEICS) and other potential environmental hazards required under IHR 2005 (up to June 2017).

• Community reporting of outbreaks, and private sector also involved • Central Public Health Laboratory and National Influenza are the

national reference laboratory that conform suspected cases 33

DEWS Targeted Disease and Condition for Surveillance

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Flow of DEWS Plus Reports and Feedbacks

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Lesson learned

• Coordination vital between BPHS &EPHS implementing partners & MOPH

• Partnership with duty barriers and community gate keepers

• With challenge of access, trained Health providers( CME) provide quality Community based RMNCH interventions to improve access for services(Rural Areas)

• Need for stronger government stewardship and domestic financing/ investment in maternal health programs.

• Scale-up of the pilot RMNCH projects ( MWH,PPH,FHH& CME) for greater impact

Challenges• Persistent insecurity impacts on Health

service delivery .• Insufficient domestic financial inputs for

health care and donor dependency• Inadequate HRH: Need for greater

numbers of qualified female health workers in the rural areas ( 3983 MW ) • Poor infrastructure ( road , bridge ,

health facility buildings )• Natural disasters and mountainous

territory ( floods , harsh and prolonged winter )• Socio cultural barriers and poor male

involvement in RMNCH program

Ways forward/priority actions

• Provision of sustainable domestic financing of proven interventions (CME, FHH,MWH) to take them to scale • Invest in training , deployment &

retention of Community Midwife• Continue mobilizing socio cultural

structures for uptake of FP & RMNCH services & prepare HF to respond• Use data from upcoming DHS & FPNA

to refocus RMNCH IP & RHCS• Improve the Maternal death review

process , implement recommendations

ThanksAny Questions or

Comments?

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