USAID Afghanistan Health Program

Improving the health of women of reproductive age and children under 5 years old, especially in rural areas

Health Care in Afghanistan: An overview

Grim health indicators: Maternal mortality: 1,600 per 100,000 live births (US: 8) Infant mortality: 165 per 1,000 (US: 7) Child mortality: 257 per 1,000, 25% die before age 5 (US: 0.35)

Most deaths are from easily preventable diseases & conditions 60% of child mortality is due to CDD, ARI & vaccine preventable diseases

40% of population has no access to health services

Human resources: Nearly 40% of Basic Primary Health Service facilities have no female health worker

Limited management & service delivery capacity of MOH

USAID program goal: reduce maternal mortality, infant mortality, and child mortality.

5

USG AFGHANISTAN HEALTH PROGRAM

Past Accomplishments $19 million (2001-2003)

Assessment National Health Facilities Survey Maternal mortality study Infrastructure 140 health facilities rehabilitated Service Delivery 3.8 millions with access to basic services through

NGOs 4.3 m measles immunizations; 10,000 deaths averted 700,000 malaria cases treated Polio eradication Family planning commodities Mental health services to vulnerable children Care for war-affected children Capacity Building 900 Traditional Birth Attendants/ Community Health

Workers trained 450 health providers trained MOH priorities/policies developed Nurse midwife/community midwife/rural health

provider curricula Training of trainers for health providers Orthopedic technicians trained Technical standards developed Health Education Diarrhea Prevention and Management launch

Current Plans $138 million (2003-2006)

Underfunded by $53.5 million

Infrastructure 400 Basic Health Centers constructed (250) and

rehabilitated (150)-- 80 under construction Service Delivery 11 million with access to basic services through

NGO Hospital renovated and quality improved Capacity Building 3,400 new community health workers, 1000

midwives, 6,000 clinic staff trained MOH capacity strengthened at the national,

provincial and district level for health planning, management, and allocation of resources; human resource development, recruitment, and deployment; pharmaceutical management, quality improvement; health information systems management; and health sector leadership

Health-focused literacy program 4 provincial level field offices established Health Education National social marketing program to promote

healthy behaviors for safe water (chlorine solution) and birth spacing

Public health education program to promote hygiene and health

Accelerating Success $51 million FY04 supplemental

Infrastructure 40 urban health facilities renovated 20 clinics replacing rented sites built 50 rural clinics constructed 3-4 provincial hospitals rehabilitated Service Delivery Basic health services expanded to include

mental health, disability and specialized health service programs

Bridge funding for services in other donor provinces

Equipment and supplies for referral facilities National infection prevention program National Maternal Neonatal Tetanus Elimination Capacity Building Institute of Health Sciences- expanded midwife

training capacity Provincial and District Hospitals management

support Health Information System and human resource

advisors 2 additional provincial field offices established Health Education Social marketing of insecticide treated bednets

for the prevention of malaria

Provinces for grants & other support

Underserved districts in highlighted provinces were listed in the RFA

Program componentsPhysical infrastructure

Service delivery

Training & capacity building

•Use of services•Improved health status•Economic development

Limitations & constraints Security, especially in south & southeast, resulting in:

Difficulty in establishing offices & posting staff Additional costs & delays

Lack of available human resources, especially female service providers in rural areas

Lack of resources in the MOH for the most basic implementation

Diversion of BPHS grants budget to cover areas left vulnerable due to “donor shift,” and delays and shortages of funds by other donors

Current USAID Project

Health Clinic Construction / Renovation

1-2 OHDACA>2 OHDACA

0 OHDACA

1611 BHC5 CHC

159 BHC6 CHC

1Model clinic

137 BHC6 CHC

74 BHC3 CHC

138 BHC5 CHC

1311 BHC2 CHC

80 OHDACA renovations

Clinic construction &rehabilitation

Clinic construction/ rehabilitation

3 yr target

To-date

By June

Clinics under construction 250 78 152Clinics rehabilitated 370 140 220Provincial hospitals rehabilitation

3-4 0 3-4

MOH using an equitable approach with a goal of 1 clinic per 30,000 population working towards1 clinic per 20,000 population

Basic Package of Health Services•Maternal and Newborn Health

•Child Health and Immunization

•Public Nutrition

•Communicable Disease

•Supply of Essential Drugs•Disability*•Mental Health** Not currently implemented

•Helps to prioritize among many health problems (public health)

•Guides the allocation of scarce human and financial resources to address priority problems (including for NGOs and donors)

•Provides direction for the rehabilitation of the health care system (start with primary care)

Service deliveryService delivery through NGO BPHS grants

3 yr target

To-date

By June

Rural Population (millions) 11.1 m 6.1 6.9 m

Underserved districts 62 49 62

Grant funds committed (USD millions)

$56 m $57 m Shortfall

• Target was the 62 underserved districts out of 154 total districts. • Funding is also supporting services in 53 other districts to cover for loss of

other donors’ funding.• USAID funding also used to cover WB & EC delays/funding shortages

Districts covered by REACH grants

Rural Population To Be Covered by Grants in REACH Priority Provinces

(population in millions) 11.1

1.81.3

4.0

6.1

1.41.0

3.2

6.9

1.61.1

4

Provincial Women of ReproductiveAge

Children Under 5 Priority TargetedUnderserved Districts

mill

ions

Total Rural Population in REACHtarget areas

Population to be Covered byGrantees Selected to Date

Cumulative to be Awarded byJune 2004

Training & capacity buildingTraining for: 3 yr

targetTo date

By June

Community Health Workers/ Traditional Birth Attendants

3,500 900 1400

Midwives/community midwives/MDs

1,000 50 300

Female literacy candidates 5,600 Starting 480

• Building training capacity: national strategy, curriculum, training centers, clinical training sites

• Females are 50% target for all provider training• Learning for Life literacy program will increase pool of females eligible to

become midwives or CHWs• Strengthened provincial presence and MOH capacity to improve policy &

govern sector

Health education & healthy products

Planned• 1.5 million condoms, 150,000 oral, & 30,000 vials of injectables

contraceptives procured & will be on the market by April 2004• Social marketing campaign to emphasize birth spacing• Malaria prevention through social marketing and targeted distribution

of insecticide treated bed nets • Improved skills of retail pharmacists & drug dispensers

Key Achievements• Prevention of diarrheal disease through national radio

campaign - 80 broadcasts on local radio stations• Chlorin – Locally produced sodium hypochlorite solution

To date 42,000 bottles sold that provide 42 million liters of safe drinking water

• Launched Number One condom and sold 100,000 in Dec 2003

Principles & approaches Full coordination with

Ministry of Health

Collaboration with and leveraging of other donors

Central and provincial level focus

Coordination with USG health group

Accelerated Program Additional

construction

Increase training & capacity building activities

Expanded service delivery through grants

Add support to hospitals

(DRAFT)Afghanistan Maternal

Health Initiative

Saving 120,000 lives

January 29, 2004

Maternal Death Risk in Afghanistan

• Risk of maternal death is one of the highest in the world--100 TIMES THAT OF U.S.

• Risk of maternal death in Badakshan of 6500-- HIGHEST EVER RECORDED IN HUMAN HISTORY

Badakshan Province has the highest maternal mortality ever

recordedMaternal Mortality Ratio

(# deaths/100,000 live births)

USA 8

Afghanistan 1,600 – 2,200

Badakshan 6,500

(CDC/UNICEF/USAID Study, 2002)

Badakshan Province

The Current SituationFawzia*, 16, illiterate, married at 13, no prenatal care, malnourished delivers at home with only her illiterate mother-in-law in attendance. She hemorrhages and is nine days donkey ride away from skilled care. She dies eight hours after the birth leaving a newborn and two year old daughter. The newborn dies after several days and the girl dies six months later.

* An indicative person representative of thousands of Afghan women.

USG Initiative to Save Mothers’ Lives

• Maternal deaths are preventable– We know what works

• USG comprehensive program– Basic health services– Roads– Literacy training– Activities to improve the role of women

• There are no quick solutions– It takes years of commitment and hard work to bring death rates

down

Expected Results Over 10 Years• 100,000 lives saved

– 35,000 mothers– 65,000 newborns

• 200,000 maternal disabilities due to child birth reduced/avoided

– Assuming security and

continuing commitment

Expanded Maternal Health Initiative:

(Red type signifies expanded elements of existing initiative)• Construct and renovate rural clinics• Provide basic health services in rural areas and launch program to prevent

post-partum hemorrhage—the biggest killer• Train midwives • Link health and education

– Incorporate health messages into school curricula and accelerated learning classes for girls

– Expand literacy programs to prepare women for entry into community health worker training

• Build secondary and tertiary roads that link communities to clinics• Improve hospital quality (HHS) in provincial hospitals• Provide health products through private sector channels and solicit

international private sector resources• Strengthen administrative capacity for health planning• Establish village women’s centers and strengthen newly-elected

Women’s Community Development Councils that facilitate women’s access to health information & services

Cumulative Lives Saved With Current and Expanded Program

Years2004 2013

100,000

120,000

Expanded Program

Current Program

KEY

With USG-Supported Maternal Health Program

Sohaila*, 19, cousin of Fawzia, married at 18, gets iron and folate tablets, tetanus toxoid immunizations and other prenatal care at the newly-built health center from a community healthcare worker. Following delivery at home, she hemorrhages. Her husband who has had community health education transports her on the upgraded feeder road to the community midwife who provides life-saving care to stop the bleeding. She survives. Her newborn daughter survives and enrolls in school at the age of five. * An indicative person representative of what the program is

striving toward.

Challenges

• Lack of security in countryside

• Cultural, geographic isolation of women

• Need for continuing commitment and support