WHO-EM/ARD/043/E
Country Cooperation Strategy for WHO and Afghanistan 2009–2013
WHO-EM/ARD/043/E
Country Cooperation Strategy for WHO and Afghanistan 2009–2013 World Health Organization 2010 ©
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Document WHO-EM/ARD/043/E Design and layout by Pulp Pictures Printed by WHO Regional Office for the Eastern Mediterranean, Cairo Contents
Acronyms and Abbreviations 5
Executive Summary 9
Section 1. Introduction 13
Section 2. Country Health and Development Challenges and National Response 17 2.1 Summary of key development and health challenges 19 2.2 Demography and main health problems 20 2.3 Macroeconomic, political and social context 20 2.4 Health status of the population 22 2.5 Socioeconomic and environmental determinants of health 24 2.6 Health systems and services 27
Section 3. Development Cooperation and Partnerships: Technical Assistance, 43 Aid Effectiveness and Coordination 3.1 Key international aid and partners in health 46 3.2 Aid effectiveness 48 3.3 Summary of key challenges and opportunities 49
Section 4. Past and Current WHO Cooperation 51 4.1 WHO cooperation overview 53 4.2 WHO structure and resources 55
Section 5. Strategic Agenda for WHO Cooperation 57 5.1 Introduction 59 5.2 Guiding principles for WHO at country level 59 5.3 Mission statement of WHO in the country 60 5.4 Strategic priorities 60 Country Cooperation Strategy for WHO and Afghanistan
Section 6. Implementing the Strategic Agenda: Implications for WHO 63 6.1 Implications for the country office in relation to the strategic priorities 65 6.2 General implications for the country office 66 6.3 Implications for WHO Regional Office and headquarters 67 Acronyms and Abbreviations
ADB Asian Development Bank AHS Afghanistan health survey AIDS Acquired immunodeficiency syndrome ANDS Afghanistan National Development Strategy (2008–2013) ANHRA Afghanistan national health resource assessment ARTF Afghan Reconstruction Trust Fund ARDS Afghan reconstruction and development system ARI Acute respiratory infection BSC Balanced Scorecard BPHS Basic Package of Health Services CCA Common Country Assessment CCS Country Cooperation Strategy CDC Centers for Disease Control and Prevention CIDA Canadian International Development Agency CSO Central Statistical Office DEWS Disease Early Warning System EC European Commission EHA Emergency Humanitarian Action EMRO Eastern Mediterranean Regional Office EPHS Essential Package of Hospital Services GAVI GAVI Alliance GCMU Grant Contract and Management Unit GDP Gross domestic product GFATM Global Fund to Fight AIDS, Tuberculosis and Malaria HEFD Health Economics and Financing Directorate HIV Human immunodeficiency virus HMIS Health Management Information System JICA Japan International Cooperation Agency JPRM Joint Programme Review and Planning Mission ICRC International Committee for the Red Cross
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IDB International Development Bank IDUs Injecting drug users IHR International Health Regulations IMCI Integrated Management of Childhood Health MDG Millennium Development Goals MICS Multiple indicator cluster survey MoF Ministry of Finance Mol Ministry of Interior MoPH Ministry of Public Health MRRD Ministry of Rural Rehabilitation and Development MSH Management Sciences for Health NIDs National Immunization Days NRVA National risk and vulnerability assessment NRVS National risk and vulnerability survey OIC The Organisation of Islamic Conference PHD Provincial health department PGC Performance-based grant contract PPA Performance-based partnership agreement PPG Performance-based partnership grant PRB Population Reference Bureau PRR Priority reform and restructuring RAMOS Reproductive-age mortality studies REACH Rural expansion of Afghan community-based health care SOWC State of The World’s Children SWAp Sector-wide approaches TB Tuberculosis TT Tetanus toxoid UNCT United Nations Country Team UNDP United Nations Development Programme UNDAF United Nations Development Assistance Framework UNFPA United Nations Population Fund UNHCR Office of the United Nations High Commissioner for Refugees
6 Country Cooperation Strategy for WHO and Afghanistan
UNICEF United Nations Children’s Fund UNIFEM United Nations Fund for Women UNODC United Nations Office on Drugs and Crime USAID United States Agency for International Development WB World Bank WHO World Health Organization WFP World Food Programme
7
Executive Summary
The first Country Cooperative Strategy Despite the continuing conflict, threat (CCS) for Afghanistan was developed in July to human security and political instability, 2005 for the period 2005–2008. The CCS there has been considerable progress in the reflects WHO’s medium-term vision for its country since 2002, especially in the area of cooperation in and with a particular country. political transformation to a democratically In late 2008, it was felt that in view of elected government. Other achievements development since then, the strategy should included: enrolling nearly 6 million children be revised and updated. With this in mind, a in primary and secondary education (35% WHO Mission visited the country from 15– of whom are young girls); availability of 22 November 2008. It comprised staff from Basic Package of Health Services (BPHS) the WHO Regional Office for the Eastern in 85% of the country; re-establishment Mediterranean and WHO headquarters of core state economic and social welfare and was led by the WHO Representative institutions; macro-economic stability and in Afghanistan. The Mission held detailed the development of commercial banking discussions with a team specially constituted and telecommunication networks led by by the MoPH, Afghanistan, to revise the first the private sector. However, the country CCS, and were briefed by H.E. the Minister continues to face several critical challenges for Public Health and the Deputy Minister to human development. Some of these of Public Health for Technical Affairs on the challenges include: widespread poverty; Government’s priorities and the technical limited fiscal resources that limit the delivery support that was anticipated from WHO of public services; insecurity arising from during the next five years. The Mission also the activities of extremists, terrorists and met with WHO staff working in the country criminals; weak governance and corruption; office, with representatives of some of the corrosive effects of a large and growing larger donors to the health sector in the narcotics industry and major human capacity country and nongovernmental organizations limitations. who had been contracted out to provide the Afghanistan’s health indicators are Basic Package of Health Services (BPHS) currently near the bottom of international in the provinces. The Mission, through indices and far worse than any other country one of its members, also met with the UN in the Region. Life expectancy is low (47 country team to brief them about the CCS years for males and 45 years for females), process and outcome and its potential for high infant, under-five and maternal mortality, shaping the health dimension of the second respectively at 129 per 1000 live births, 191 UN Development Assistance Framework per 1000 live births and 1600 per 100 000 (UNDAF) for Afghanistan that was currently live births, and an extremely high prevalence being initiated in the country. of chronic malnutrition and widespread occurrence of micro-nutrient deficiency.
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There is a high burden of communicable programmes with those of the Government. diseases. Some of the major challenges The overarching priority of the health sector and constraints faced by the health sector is to address priority health issues through include: inadequate financing for many of a universal coverage of BPHS supported the key programmes and heavy reliance on by a strengthened referral network that external sources of funding; insufficient and links patients with hospitals that provide inadequately trained health workers and the Essential Package of Hospital Services a lack of qualified female health workers, (EPHS). It appears that in the medium term particularly in the rural areas; lack of access the Government would like to continue the to health care due to dispersed populations; practice of contracting out the provision of poor quality of services provided; lack of BPHS to nongovernmental organizations national capacities for health planning and present in Afghanistan. Recently, concerns management, especially in the areas of have been raised about the quality of governance, health care financing, human services provided, the costing per capita resource development, for monitoring, for delivering BPHS and of ensuring access evaluation and analysis of the health situation to populations in security-compromised at central and especially so at the provincial areas and in provinces that are sparsely level and lack of appreciation of the role of populated or which have poor infrastructure social determinants of heath in the national for transport. Another concern was that context and of the need for intersectoral due to contracting out the BPHS and action for improving health outcomes. EPHS to nongovernmental organziations, the provincial health authorities found In response to the above-mentioned themselves with a limited and ill-defined developmental challenges facing the role in health care delivery at provincial and country a very positive development has district levels, thus creating tensions. been the preparation of a five-year (2008– 2013) Afghanistan National Development Approximately 60% to 80% of the Strategy (ANDS). It provides a roadmap for Afghanistan’s health sector’s operating transition towards stability, self-sustaining budget is financed by external donors. As growth and human development. It is a part of its mandate, the WHO CCS Mission Millennium Development Goals (MDGs)- undertook a review of the development based plan that serves as Afghanistan’s cooperation and partnerships in the health Poverty Reduction Strategy Paper (PRSP). sector, of aid effectiveness and coordination. As an integral component of this strategic A major challenge in this connection was plan the Ministry of Public Health (MoPH) the reduced impact of the financial and has formulated a health and nutrition technical support given by the international strategy that provides strategic directions community to Afghanistan’s health sector for reducing morbidity and mortality and for due to continuous conflict in many parts of the institutional development. The preparation of country that hinders access. The insecurity these strategy documents would go a long also limits the ability of development partners way in ensuring that all the stakeholders in and the MoPH from effective monitoring the health sector align their priorities and and supervision of the performance of
10 Country Cooperation Strategy for WHO and Afghanistan nongovernmental organizations in delivering of the country office. WHO’s role as the the BPHS and EPHS resulting in differences lead technical agency is well recognized, in the quality of health services delivered however, its coordination and information- in various districts. There was a lack of sharing role needs improvement. Certain uniformity or standardization of approaches, areas of technical expertise needed expectations, procurement services, funding upgrading, such as policy formulation and and reporting mechanisms among different strategic planning in different aspects of donors resulting in high transaction costs health systems, emergency preparedness on the part of the Grants Contract and and response to humanitarian crises, social Management Unit (GCMU), MoPH and the and environmental determinants of health nongovernmental organizations The various and in mental health. There is also a need coordination mechanisms established by to upgrade its leadership and coordinating the Government seem to be functioning role in the field of maternal and child health. suboptimally due to lack of leadership. In It needs to play a more active role at the spite of these challenges, the Government policy level for promoting intersectoral and international community is committed collaboration for improving health outcomes. to the Afghanistan Compact that ensures Based upon a careful analysis of continuous financial and technical support the country’s health and development from external donors to the national challenges, the national and international development objectives, including national response to these challenges and taking into health objectives. account to the Organization’s own priorities, The well-defined goals, priorities and strengths and strategic plans as articulated monitoring framework of the ANDS (2008– in the Eleventh General Programme of Work 2013) and the Health and Nutrition Strategy from 2006–2015 and in its Medium Term (2008–2013) ensures that international Strategic Plan for the period 2008–2013, assistance is in alignment with and contributes the Mission identified the following strategic to these goals. However, in spite of the fact priorities in close consultation with national that the Government has developed an counterparts. aid effectiveness strategy, in line with the Health system strengthening based on Paris Declaration for Aid Effectiveness and the values and principles of primary Afghanistan’s international obligations, there health care (main focus: human was a need to improve standardization of resource development, stewardship and approaches, procurement services, joint governance; health information system programming and implementation and tools and health care financing). and guidelines in order to improve quality Social and environmental determinants and maximize resource use, in other words of health. harmonization is lagging. Control of communicable and noncommunicable diseases (main Past and current WHO cooperation with focus: communicable diseases and the Government was reviewed with a view mental health). to identifying weaknesses and strengths
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Reproductive and child health (main WHO support for policy formulation and focus: reproductive health and child strategic planning on a variety of pressing health). health issues. At the same time, WHO Emergency preparedness and response support would also be needed for generating (main focus: emergency preparedness evidence for policy formulation and planning and International Health Regulations programmes for areas that currently lack (2005)). the required evidence for this purpose (e.g. noncommunicable diseases, road traffic Under each of the above strategic accidents, etc.) through carefully designed priorities a set of strategic approaches has surveys/research studies. been formulated. Finally, the Mission carried out an The Mission feels confident that these analysis of the current technical capacities priorities are aligned with the national health of the country office to deal effectively with priorities and take into account WHO’s each of the above-mentioned strategic relative advantage. It was evident from the priorities and made recommendations discussions held with MoPH officials that about strengthening them where they were in the period covered by the present CCS, considered suboptimal. greater emphasis will be placed on seeking
12 Section 1
Introduction
Section 1. Introduction
In order to strengthen the effectiveness The timing of the revision and updating of of its cooperation with Member States, the first CCS was opportune for two main the World Health Organization (WHO) has reasons. The first reason was the finalization institutionalized the Country Cooperation and approval of the Afghanistan National Strategy (CCS) as an integral part of its Development Strategy (ANDS) for the period Country Focus Policy. The CCS reflects 2008–2013 in April 2008 after two years of WHO’s medium-term vision for its extensive analytical work and consultations. cooperation in and with a particular country. As part of the ANDS a detailed health and It defines a strategic framework for working nutrition strategy for the same period had with that country, highlighting what WHO will been developed by the MoPH. Thus, the do, how it will do it and with whom. The CCS CCS Mission had access through the ANDS also serves as the main WHO instrument for and the health and nutrition strategy to the aligning its own priorities and strategic plans latest information on the achievements with national health development plans and of and challenges facing socioeconomic priorities and for harmonizing its work with and health development in the country other multilateral and bilateral agencies and about the national priorities and during the coming 3–5 years. strategic plans for various sectors of the Government. The second reason was the The first CCS was formulated in July initiation of preparations for the formulation 2005 for the period 2005–2008. As the of the second UN Development Assistance country continues to face enormous health Framework (UNDAF) for Afghanistan and development challenges aggravated by afforded an opportunity for the revised CCS insecurity and impending humanitarian to serve as WHO’s input into the UNDAF. crises, it was timely to update and revise the first CCS. With this in view, preparatory The WHO CCS Mission had frank and work was initiated by the WHO country detailed discussions with the national office in August 2008 to review the first counterparts and a highly informative CCS and to revise Sections 2 and 4 of the briefing on health priorities and programmes report dealing respectively with the country’s by the H.E. Dr Amin Fatimie, Minister of health and development challenges and Health, Government of Afghanistan and national responses and past and current by Dr Faizullah Kakar, Deputy Minister of WHO cooperation. The MoPH (MoPH) was Public Health for Technical Affairs. Detailed informed of the need to revise the first CCS discussions were also held with the WHO and was requested to establish a working Representative and other professional staff group comprising senior officers dealing working in the WHO country office, with with strategic planning to hold discussions some of the major donors to the health with the visiting WHO CCS Mission from sector as well as with representatives of 15–22 November 2008. some of the nongovernmental organizations
15 CountryCountry Cooperation Cooperation StrategyStrategy for for WHO WHO and andYemen Afghanistan who had been contracted out to provide the The CCS Mission during its work had BPHS in some provinces of the country. the opportunity to use the WHO Country Cooperation Strategy e-guide, Modules The Mission also had the opportunity to 2 and 3, developed by the Department meet and interact with the staff of provincial of Country Focus in WHO headquarters. health departments from all over the country The purpose of this e-guide is to increase who were in Kabul for a meeting with the awareness of the importance of the WHO central MoPH. One of the members of the CCS, to improve the quality of the CCS WHO CCS Mission also attended a meeting process and the document produced, and to of the UN country team in Kabul to appraise promote the use of the CCS. the CCS.
16 Section 2
Country Health and Development Challenges and National Response
Section 2. Country Health and Development Challenges and National Response
2.1 Summary of key major human capacity limitations development and health throughout both the public and private challenges sector.
Despite the continuing conflict, threat Afghanistan’s health indicators are to human security and political instability, currently near the bottom of international there has been considerable progress in indices and far worse than any other country the country since 2002. In addition to the in the Region. Life expectancy is low, political progress that has included three infant, under-five and maternal mortality rounds of free and fair elections, some of is very high and there is an extremely high the major achievements include: enrolling prevalence of chronic malnutrition and 6 million children in primary and secondary widespread occurrence of micro-nutrient education (35% of whom are young girls); deficiency. Some of the major challenges availability of basic package of health and constraints faced by the health sector services in 85% of the country; the return include: of over five million refugees; disarmament, inadequate financing for many of the demobilization and reintegration of over key programmes; 63 000 former combatants; re-establishment heavy reliance on external sources of of core state economic and social welfare funding; institutions; macro-economic stability and inadequately trained health workers the development of commercial banking and lack of qualified female health and telecommunication networks led by the workers, private sector. particularly in the rural areas; lack of access to health due to However, the country continues to dispersed population, geographical face several critical challenges to human barriers and lack of transportation development, which include: infrastructure; widespread poverty; poor quality of services provided; limited fiscal resources that limit insecurity that makes implementation of delivery of public services; programmes difficult; insecurity arising from the activities of lack of effective financial protection extremists, terrorists and criminals; mechanisms for poor households weak governance and corruption; to receive required care without poor environment for private sector experiencing financial distress; investment; lack of mechanisms for effective corrosive effects of a large and growing regulation of for-profit private sector narcotics industry; clinics and pharmacies.
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2.2 Demography and main distribution of quality health services; and health problems (vi) low capacity to implement effective and efficient health services at all levels ofthe According to data from the Central Statistic health system (MoPH 2004).2 Office (CSO) Afghanistan’s population is 24.5 million (CSO 2007/2008). According to 2.3 Macroeconomic, political available demographic data, the distribution and social context of the population varies dramatically across In response to developmental challenges the country. In 2001, the 77 districts with a facing the country, a five-year national population density below 20 inhabitants per development strategy has been prepared km2 hosted 13% of the population, scattered after two years of analysis and priority- over 55% of the country’s area. In the 120 setting drawing on extensive national and districts with a population density below 30 subnational consultations for the period per km2, representing 70% of the country’s 2008–2013. It provides a roadmap for area, lived 24% of the population. 34% of transition towards stability, self-sustaining the total population lived in the 71 districts growth and human development. It is a with a population density of more than 100 Millennium Development Goals (MDGs)- inhabitants per km2. based plan that serves as Afghanistan’s Fifty two (52%) of the population is under Poverty Reduction Strategy Paper (PRSP). 18 years of age with a life expectancy for The pillars of the national strategy are females of 45 and for men 47 years. Life 1) security; 2) governance, rule of law and expectancy of men exceeds that of women, human rights; and 3) economic and social a phenomenon that is solely observed in development. Security requires achieving Afghanistan and that might have its cause nationwide stabilization, strengthening in an unprecedented high maternal mortality law enforcement and improving personal rate. With an estimated total fertility rate of security for every Afghan. Governance, 7.2 per woman and an average population rule of law and human rights requires growth rate of 2.0% per year, the population strengthening democratic practice and of Afghanistan is increasing very rapidly.1 institutions, human rights, the rule of law, The key problems facing Afghanistan delivery of public services and government and its health system are: (i) high levels of accountability. Economic and social infant (129/1000) and under-five (199/1000) development means reducing poverty, mortality rates; (ii) one of the world’s highest ensuring sustainable development through maternal mortality ratios (1600/100 000 live a private sector-led market economy, births); (iii) elevated levels of malnutrition improving human development indicators throughout the population; (iv) high incidence and making progress towards the targets of of communicable diseases; (v) inequitable the MDGs.
1 Afghanistan Multiple Indicator Cluster Survey. Kabul, UNICEF, 2003. 2 Capacity building plan for central and provincial Ministry of Public Health administration staff. Kabul, Ministry of Public Health, May 2004.
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Under these three pillars, there are recorded rapid growth since 2001. The main several cross-cutting themes i.e. capacity- driver of growth has been the construction building, gender equity, counter narcotics, sector, which has been boosted by foreign regional cooperation, anti-corruption and efforts to rebuild the infra-structure and environment. Health and nutrition is one of the development of private housing. The the priorities under the pillar of economic and country’s biggest economic sector is social development and a detailed health technically illegal. Afghanistan accounted for and nutrition strategy has been developed roughly 90% of global opium production in that is discussed later in the document. 2007 and opium contributes to over one third of the total gross domestic product (GDP) of 2.3.1 Political and administrative the country. structures The GDP per capita (in purchasing power The structure of the Afghan Government parity (PPP) terms) in Afghanistan has risen is unitary; all political authority is vested in from US$ 683 in 2002 to US$ 964 in 2005.3 the Government in Kabul. The subnational Non-drug GDP has increased more than administration comprises 34 provinces and 50%, primarily reflecting the recovery of 364 districts, with each province having agriculture from severe drought, a revival between 3 and 27 districts. Provinces and of economic activity and the initiation districts are legally recognized units of of reconstruction. Afghanistan’s poverty subnational administration. They are not level continues to remain high (details are intended to be autonomous in their policy given later in the document). Although no decisions, although there have been some specific survey has been conducted, the attempts at establishing local participative overall unemployment rate is estimated at bodies. The Constitution specifies that 32%.4 The factors identified as inhibiting a provincial council be elected in each employment and economic growth are: (i) province, and also specifies the election of weak state of national institutions; (ii) lack of district and village councils. Each province support services, including key infrastructure has one provincial municipality, while and market access; (iii) lack of access to most districts have one rural municipality, capital and financial services; and (iv) lack of which are in principle a separate level of advanced entrepreneurial skills, knowledge government and have limited autonomy in and technology. budget execution and in budget preparation. The Ministry of Interior controls their staffing The informal economy in Afghanistan establishment and approves their budgets. continues to account for 80% to 90% of the total economy; women work primarily in this 2.3.2 Socioeconomic context sector; sociocultural reasons and a lack of Partly owing to its previous poor state opportunity prevents them from participating after years of conflict, the economy has in formal economic activities. The economy
3 Afghanistan human development report. Centre for Policy and Human Development, 2007. 4 IRC Labour Market Information Survey, 2003 and as quoted in Common Country Assessment for the Transitional Islamic State of Afghanistan, UN System Kabul, October 2004.
21 CountryCountry Cooperation Cooperation StrategyStrategy for for WHO WHO and andYemen Afghanistan has legal and illegal components. The relevant to Afghanistan and adding a ninth former is centred on agriculture, commerce, goal on enhancing security. manufacturing, handicrafts and transport while the latter includes extensive opium 2.4 Health status of the production, along with widespread population unauthorized timber harvesting and mineral The major problems facing Afghanistan extraction. and its health system are: (i) high levels of Afghanistan’s social indicators rank at infant and under-five mortality rates; (ii) one or near the bottom among developing of the world’s highest maternal mortality countries, preventing the fulfilment of rights ratios; (iii) elevated levels of malnutrition to health, education, food and housing. throughout the population; (iv) high Afghanistan’s health development index incidence of communicable diseases; (v) stands at 0.345 and places Afghanistan inequitable distribution of quality health 174 out of 178 countries in terms of global services; and (vi) low capacity to implement effective and efficient health services atall ranking.3 Since 2002, important progress levels of the health system (MoPH, 2004).2 has been achieved, but much remains to be done in order to reach a significantly Table 1 provides an overview of the most strengthened social infrastructure, realize recent estimates of health and demographic the rights to survival, livelihood, protection indicators in Afghanistan. and participation and reach the targets of Apart from programme-specific the MDGs. information, no nationwide information was 2.3.3 The MDGs in Afghanistan currently available that could indicate the burden of disease and its trend, or morbidity When the Millennium Summit was held and mortality patterns, such as leading in September 2000, Afghanistan was in the causes of death. The top 10 diseases seen midst of a conflict. It was only in March 2004 in the outpatient clinics in health facilities in that the Government officially endorsed the 2007 in Afghanistan as reported by the health MDGs and began participating in this effort. information systems are: acute respiratory As the country was then recovering from two infections; diarrhoeal diseases; urinary tract decades of conflict, it was decided to modify infections; trauma; psychiatric disorders; the calendar for achieving the MDGs and to malaria; tuberculosis suspected cases; amend the benchmarks taking into account severe childhood illnesses; viral hepatitis; the still devastated state of the country. In pertussis. The information in Table 2 can be other words steps were taken to ‘Afghanize’ taken as a proxy reflection of the ill-health the MDGs. This involved extending the time status in Afghanistan. period for attaining the targets to 2020, revising the targets to make them more
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Table 1. Recent health and demographic indicators for Afghanistan
# Indicators Value Year Source 1 Total population (million) 24.5 2007-2008 CSO 2 Settled population (million) 23 2007-2008 CSO 3 Nomadic population (million) 1.5 2007-2008 CSO 4 Women of reproductive age (15–49 years) 5.64 2007-2008 CSO (million) 5 Children under-five years of age (million) 4.9 2007-2008 CSO 6 Life expectancy at birth, females (year) 45 2003 PRB 7 Life expectancy at birth, males (year) 47 2003 PRB 8 Total fertility rate (per woman) 7.2 2008 SOWC 9 Infant mortality rate (per 1000 live births) 129 2006 AHS 10 Under-five mortality rate (per 1000 live births) 191 2006 AHS 11 Maternal mortality ratio (per 100 000 live births) 1600 2002 RAMOS 12 Contraceptive prevalence rate (%) 15.4 2006 AHS 13 Skilled antenatal care (at least one visit, 32.3 2006 AHS excluding tetanus toxoid (TT)) (%) 14 Pregnant women receiving at least two doses of 23.8 2006 AHS TT (%) 15 Skilled birth attendance (%) 18.9 2006 AHS 16 Exclusive breastfeeding (%) 83 2006 AHS 17 Underweight prevalence under five (%) 39.3 2004 NNS 18 DPT3 coverage (%) 82.9 2007 NEPI 19 Measles vaccination rate (%) 70.3 2007 NEPI 20 Fully immunized (12-23 months) (%) 27.1 2006 AHS 21 Vitamin A receipt in last 6 months (6–59 months) 79.7 2006 AHS (%) 22 Polio laboratory-confirmed cases (number) 31 2008 NEPI 23 ITN utilization rate among children under-five 5.7 2006 AHS years of age (%) 24 HIV prevalence, adult (%) <0.1 2007 UNAIDS 25 Estimated tuberculosis prevalence (all cases per 231 2008 NTP 100 000 population) 26 TB case detection rate (%) 70 2007 NTP
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# Indicators Value Year Source 27 TB (DOTS) treatment success rate (%) 89 2007 NTP 28 Hospital beds per 10 000 population 4.2 2004 NHA 29 Household access to drinking-water from pump 40.3 2006 AHS or protected spring (%) 30 Household with access to sanitary latrine (%) 75.1 2006 AHS
Sources : CSO = Central Statistical Office PRB = Population Reference Bureau SOWC = State of The World’s Children RAMOS = Reproductive-age mortality studies AHS = Afghanistan health survey NNS = National nutrition survey NEPI = National Expanded Programme of Immunization NTP = National tuberculosis programme NHA = National health facility assessment UNAIDS= Joint United Nations Programme on HIV/AIDS
Table 2. The top ten diseases in Afghanistan 2007
No Diseases 1 Cough and cold 2 Ear, nose and throat 3 Pneumonia 4 Acute watery diarrhoea 5 Acute bloody diarrhoea 6 Diarrhoea with dehydration 7 Malaria 8 Urinary tract infections 9 Psychiatric disordersa 10 Trauma
Source: Health management information system 2007.
2.5 Socioeconomic and key determinants that influence health and environmental determinants health equity in Afghanistan. of health 2.5.1 Poverty A wide range of socioeconomic and Poverty in Afghanistan is complex and environmental determinants influence health multidimensional due to low assets (physical, outcomes. What follows is a summary of the financial and human), years of insecurity
24 Country Cooperation Strategy for WHO and Afghanistan and drought, cultural traditions and poor development index (GDI) for Afghanistan at infrastructure and public services. The 0.310 is second lowest out of all countries. Government has undertaken detailed poverty Although women and girls constitute nearly diagnostic work—to better understand the one-half of the country’s population, their causes and effects of poverty and propose status remains undermined by a male- pro-poor growth strategies as parts of the dominated society and a lack of gender national strategy. The Government’s national sensitivity in data collection and analyses. risk and vulnerability assessment (NRVA) Violence against women is one of the main conducted in 2007, indicates that 42% (12 security problems in Afghanistan. According million people) of the population were living to a study conducted by the United Nations below the poverty line with incomes of about Fund for Women (UNIFEM) in Afghanistan US$ 14 per month per capita and 20% were on violence against women, 30.7% of cases located very close to the poverty line. Food resulted from physical violence, 30.1% from poverty was estimated at about 45%, in psychological violence, 25.2% from sexual other words, inability to purchase sufficient violence and 14.0% from a combination of food to provide a minimum food intake of the above, in addition to kidnapping and 2100 calories per day. attempted kidnapping. The study reported that the majority of the acts of violence (82%) Within the country, significant inequality were committed by family members.5 exists between the rural, Kuchi (nomadic pastoralists) and urban population. In Afghanistan, despite legislation Meanwhile, gender inequality is one of the forbidding under-age marriage, 57% of girls highest in the world as the vast majority of are married before the age of 16 and 70% women do not participate in paid economic to 80% of women face forced marriages. activity. Consumption inequality is also According to the United Nations Population of great concern as the top 10% of the Fund (UNFPA), the mean age at marriage in population’s share of total consumption is Afghanistan is 17.8 years for women and 21.1% while the share of the bottom 10% 25.3 years for men. Early marriage of girls, is only 3.6%. Poverty is more severe in and consequently early pregnancy and child the northeast, central highlands and parts birth, puts women at high risk of maternal of the southeast. The rural population, mortality. The majority of rural Afghan who account for the majority of the poor, women work at home in agriculture and represent nearly 80% of the population. livestock management but without being The main characteristic of rural poverty is renumerated. Cultural constraints restrict the high food insecurity and a lack of access to movement of women and limit their access infrastructure and basic public services. to work outside their home and their access to health care. Largely as a result of two 2.5.2 Women and gender decades of war, there are nearly 1 million The status of Afghan women is one widows in Afghanistan with an average age of the lowest in the world. The gender of 35 years.
5 http: //www.unifem.org/afganistan/media/pubs/08/factsheet. html, accessed 29 November 2010.
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Finally, health indicators for both women girls’ school at all. At the primary level there and children remain excessively poor. For is one girl pupil for every two boys and at example, almost two-thirds of tuberculosis secondary level one girl pupil for every three patients are female in Afghanistan, which to four boys. Retention of girls is a problem is an exception. The female mortality rates in schools at all levels. Many reopened girls’ reflect the dire conditions in which most of schools have been destroyed by Taliban or them live. Although a significant increase local military fractions. Major challenges in the in the number of female health workers field of education include: poor institutional has potentially broadened female access capacity to plan and manage education to health care, it does not offset the effects programmes; poor quality of education and of widespread violence against women in outdated curriculum; shortage of qualified Afghanistan. teachers, particularly women; and lack of training and shortage of spaces for learning 2.5.3 Education and essential teaching–learning material.
Twenty-eight (28%) percent of the 2.5.4 Vulnerability population (6 years and older) in the country are literate. The urban population has a Among vulnerable groups are female- literacy rate of 56%, households in the rural headed households, including widows, areas 23%; while only 6% of the Kuchi can people with physical or mental disabilities, read. Almost half of the men and more than people who live in geographically isolated 85% of women in Afghanistan are illiterate.1 areas, the landless, orphans, but also Disparities exist between provinces, children, women, nomads, the elderly, reflecting the conservative, tribal societies internally displaced persons and returnees. where gender segregation is common (Kabul The national risk and vulnerability assessment Province school enrolment 76%, Uruzgan in 2005 revealed that the highest proportion Province 19%.6 of households with low dietary diversity and poor food consumption is found in central The gross enrolment ratio (combined for Afghanistan and Nuristan province in the primary, secondary and tertiary levels) has east. These areas have bad roads and difficult risen to 59.3% in 2005, up from 45% in access to markets throughout the year. The 7 2002. In 2005, the total number of students northern parts of the country present higher in primary schools (grades 1–6) was 4.25 dietary diversity related to higher and more million of whom 35.9% were girls. The total diversified local production. National risk number of students enrolled in secondary and vulnerability assessment (NRVA) 2005 and high schools was 0.63 million and 24.1% data indicate that 30% of households eat, on were females. Only 19% of the schools are average, below their daily requirement and designated as girls’ school and in 29% of population groups below minimum levels educational districts there are no designated of dietary energy consumption, including
6 Common Country Assessment for the Islamic Republic of Afghanistan. United Nations System, Kabul, October 2004. 7 Afghanistan national human development report 2004. United Nations, 2004.
26 Country Cooperation Strategy for WHO and Afghanistan nomads (24%), rural (30%), urban (31%) and 2.5.6 Water and sanitation with a national figure of 30%. The identified forms of vulnerabilities found in the cities Access to safe drinking-water varies (Kabul, Jalalabad and Herat) include: income considerably throughout the country. Only failure (people with disabilities, elderly, 31% of households have access to safe widowed, female-headed families), food drinking-water,8 with Kuchi household having insecurity (families with high dependency the lowest level at 16%. In some provinces rates, less diverse income sources, women such as Bamyan, Bahglan and Sar-I-Pul the with disabilities) bad health status (working figures are less than 6 10%. By and large, children, poor housing, people with physical urban households have nearly three times disabilities, especially women, war victims), higher access to drinking-water (64%) as social exclusion and disempowerment. compared to rural households (26%). The Afghanistan health survey, 2006, reveals that The National Disability Survey in 24.9% of households have no toilet facilities Afghanistan (2005) found the prevalence of while the remaining households have access disability to be 2.7% (95% CI 2.4%–3.1%). to some kind of sanitation facilities, e.g. a Over half of persons with disability live traditional latrine within their compounds in the western and central regions of the and households. Sanitary means of excreta country with the vast majority (69.7%) living disposal are scarce. Sanitations systems in in rural settings. The distribution of persons major cities are lacking, resulting in a high with disabilities has two distinct peaks, the number of waterborne diseases, especially first between 4 and 9 years (25.8%) and during the summer months (e.g. outbreaks the second in the over-45 year age group of cholera). The Government has established (26.8%). The majority of persons with a National Environmental Protection disability were men (58.9%). Agency with responsibility for developing and implementing national environmental 2.5.5 Food security policies and strategies. Access to food is limited due to remoteness, 2.6 Health systems and bad roads and transportation, seasonal services variation and low food production. Families cannot afford to purchase food as needed due 2.6.1 Priority public health problems to the low income and large family size. Diversity and programmes of food is very poor due to unavailability of different food items, low purchasing power The following sections address the priority and low levels of nutrition-related education. public health problems of maternal and child The devastation caused by the drought has health, malnutrition, communicable and left more than 5 million Afghanis dependent for noncommunicable diseases and emergency survival on food aid and assistance from UN and humanitarian crisis. and private relief organizations.
8 Afghanistan health survey. Baltimore, John Hopkins University, 2006.
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2.6.1.1 Maternal and child health work is to assist, supervise and monitor the implementation of reproductive health Poor maternal health continues to be policies at the provincial level. The shortage a major challenge for the Afghan health of skilled birth attendants, especially in rural system. Maternal mortality is estimated to be areas, is a major constraint in delivering very high at 1600 per 100 000 live births, the reproductive health services. second highest mortality rate in the world. Reproductive health services are provided Though the infant mortality rate has as an integrated package in the BPHS and decreased from 165 per 1000 live births in EPHS facilities. The percentage of pregnant 2002 to 129 per 1000 live births, and the women receiving care from skilled birth under-five child mortality rate from the high attendants has increased from 5% in 2002 baseline level of 257 per 1000 live births to to 32% in 2006 and delivery by skilled birth 191 per 1000 live births—both are among attendants has increased from 5% in 2002 the world’s highest. The major causes of to 19% in 2006. Thirty-two (32%) percent of morbidity and mortality among children women make at least one visit to a skilled include measles, diarrhoea, acute respiratory provider for antenatal care, but not all infection, malaria and micronutrient receive the required antenatal services. Nine deficiencies, such as scurvy. The annual in ten rural women deliver babies at home number of deaths from diarrhoea among without skilled birth assistance or proper children under five is estimated to be 85 000. referral services for essential and emergency The Integrated Management of Childhood obstetric care. Among the newborn infants Health strategy (IMCI) was formally endorsed of mothers who died, only 1 out of 4 has a by the MoPH in 2003 and by the end of 2007, chance of surviving until their first birthday. 72% of primary health care facilities in all Depending on the location, between 30% and provinces had at least 60% of the providers 90% of women in rural areas cannot access trained in IMCI. One of the main constraints health care. The average Afghan woman had to implementation was the low rate of follow- 7.4 children in 2004. The high fertility rate, up visits conducted after training with only coupled with early marriage and limited 12% of providers followed up. The GAVI access to modern family planning methods Alliance (GAVI) health system strengthening and health facilities have a devastating toll proposal, worth about US$ 1 million for a on the health of both mothers and children. period of three years (2008–2010), has been Contraceptive prevalence rate increased approved and funds will be used to support from 10% in 2003 to 15.4% in 2006. the child health component of training Educational status, wealth and geographical community health workers. Support for child access play a key role in the use of health health is also being provided by the United services by women. While distance is an States Agency for International Development important barrier to the use of maternal (USAID)/BASIC and UNICEF. The former has health services, many women who live close identified five strategic areas for support in a to health facilities do not receive essential 18-month plan with a budget of US$ 2 million services. Each provincial health directorate that include child health policies and strategies, has a reproductive health officer whose improvement of child care in community,
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BPHS and EPHS levels and strengthening of 2.6.1.2 Malnutrition health system components. UNICEF’s country programme worth US$ 18 million has been Fifty-four (54%) percent of Afghan extended to 2009. Its support for child survival preschool children are malnourished. Chronic includes support for the immunization malnutrition is widespread, between 40% programme (introduction of Hib vaccine and 60% of Afghan children are stunted, in 2009 and national immunization days 39% were underweight; and 7% wasted, (NIDs)) and nutrition (infant and young child the latter is an indicator of acute malnutrition feeding, including a pilot project on ready- (Table 3). Multiple sources indicate that to-use therapeutic foods for community the introduction of timely complementary management of uncomplicated severe acute foods is low with increasing stunting rates 9 malnutrition). The MoPH has constituted in children between 6 and 24 months. The a working group to develop a child health prevalence of underweight among non- situation analysis and policy. pregnant Afghan women 15–49 years of age was almost 20%. Factors contributing to malnutrition include: food insecurity at household and community level; the
Table 3. Prevalence of various nutrition-related parameters by population group
Target Group Median Urinary Received Anaemia1 Stunting2 Under- Wasting4 urinary iodine vitamin A (%) (%) weight3 (%) iodine deficiency capsule (%) (µg/L) (% <100 within µg/L) the last 6 months (%) Preschool -- -- 81.0 37.9 53.7 39.3 6.7 children 6–59.9 months Children 49.0 71.9 ------7–11.9 years Non-pregnant 42.0 74.7 -- 24.7 -- 20.8 -- women 15–49.9 years Men ------7.1 ------18–60.0 years
1 Anaemia defined as Hb<11.0 g/dL in children, Hb<12.0 g/dL in women, and Hb<13.0 g/dL in men (Hb adjusted for altitude, pregnancy status and cigarette smoking). 2 Height-for-age Z-score <-2. 3 Weight-for-age Z-score <-2 in preschool children, and BMI <18.5 in non-pregnant women. 4 Weight-for-height Z-score <-2. -- Not applicable
9 National Vitamin and Mineral Deficiency Survey, Afghanistan. MoPH, UNICEF, CDC, 2004.
29 CountryCountry Cooperation Cooperation StrategyStrategy for for WHO WHO and andYemen Afghanistan prolonged drought situation in the last few tuberculosis care (DOTS) greatly assisted years along with the long-standing effect by the expansion of the BPHS. About 500 of war on agriculture; seasonal variation diagnostic centres are operational and of food availability; large families with low several international partners (Canadian income; low purchasing power for quality International Development Agency (CIDA), foods due to poverty; poor health nutrition Global Fund to Fight AIDS, Tuberculosis and education to understand the use of balanced Malaria (GFATM), Italian Corporation, Japan foods; gender discrimination in relation to International Cooperation Agency (JICA), food consumption; improper breast and United States Agency for International complementary feeding practices and co- Development (USAID) and the World Food existence of diseases such as diarrhoeal Programme (WFP) have supported the diseases, acute respiratory infections (ARI), expansion. Case notifications showed rapid malaria, worm infestation and tuberculosis. increase: from 21 844 in 2005 to 28 689 in 2008: the case detection rate is reportedly 2.6.1.3 Communicable diseases 70%. Treatment success rates are about Communicable diseases are an important 90%. However, access to tuberculosis public health and development problem care is still limited, particularly in remote in Afghanistan. Available information and hard-to-reach areas and the quality of indicate that, in addition to ARI and tuberculosis care is not yet optimal. diarrhoea that affect children (as outlined Malaria is endemic in Afghanistan, above), tuberculosis, malaria and vaccine- particularly in 14 out of 34 provinces where preventable diseases such as measles and 14 million people live. Returnees from neonatal tetanus significantly contribute neighbouring countries, internally displaced to the ill-health of the Afghan population. persons and nomads are also vulnerable. In Social determinants of health such as 2008, a total of 4641 283 cases of malaria poverty, gender, lack of health education were reported in Afghanistan. With the and limited access to health services have assistance of partners such as the Global also contributed to the high magnitude of Fund to Fight AIDS, Tuberculosis and Malaria communicable disease problems. (GFATM), nongovernmental organizations Tuberculosis is still highly epidemic. and USAID, malaria care has been scaled up Afghanistan is one of the 22 high-burden through expanding the network of laboratory countries in the world. The estimated services, introducing rapid diagnostic tests at incidence of all tuberculosis cases is about the community level and providing free long- 161 per 100 000 and the mortality ratio is lasting insecticide-treated bednets (LLINs) 32 per 100 000 population.10 Almost 80% to affected provinces. However, access of such patients are young adults, and more to diagnostic services and the coverage importantly, about two-thirds of all patients of LLINs are still limited. Leishmaniasis is are female. Since implementation began in also endemic. Cutaneous leishmaniasis 2002, Afghanistan has rapidly expanded is particularly rampant in Kabul where
10 Global tuberculosis control. Geneva, WHO, 2008.
30 Country Cooperation Strategy for WHO and Afghanistan the estimated incidence has drastically November, 31 cases had been reported increased from 15 000 in 1995 to 70 000 at (as opposed to 14 for the same period in present. Afghanistan, with the assistance 2007) largely from provinces in the south of partners, has expanded diagnostic and (Kandahar (12), Urzugan (5) and Helmand (7). treatment services. However, despite this Afghanistan will increase the number of NIDs rapidly increasing burden, the disease is for nationwide and sub-NIDs for primarily still largely neglected by the international affected areas. community of donors and funding for Routine immunization (DPT3/HepB3) has diagnosis and treatment is limited. reportedly shown very high coverage rates HIV/AIDS epidemic is at an early stage of 83% in 2007 and 85% in 2008, drastically in Afghanistan and is concentrated among increased from 41% in 2001. Measles high-risk groups, mainly injecting drug vaccination coverage (routine) has also users (IDUs) and their partners. Reliable shown reportedly good coverage of 70% in data on HIV prevalence in Afghanistan is 2007 and 75% in 2008. A second dose of sparse. To date, 478 HIV cases have been measles vaccine was introduced as a part of reported. However, it is estimated that there routine immunization, but its coverage was could be between 1000 and 2000 Afghans only 16% in 2007 and 40% in 2008. Measles living with HIV. Afghanistan has developed catch-up campaigns started in 2002 and a national HIV/AIDS strategic framework were followed in 2003, 2006, 2007 and 2009. and has started scaling up of HIV/AIDS The number of reported cases of measles care, prevention and treatment to ensure was reduced from 88 762 in 2001 to 2861 universal access to health care services for in 2007 and 1149 in 2008. However, there most-at-risk populations and implement a have been small outbreaks: a total of 1141 multisectoral response. However, progress outbreak cases were reported in 2007 and is often limited due to stigma, discrimination 1340 cases in 2008. The cases reported and other socioeconomic factors. during outbreaks (recorded and reported through the health management information Vaccine-preventable diseases are a very system) are not part of the total number of important public health problem. Polio reported cases through the system. eradication is a national priority. Afghanistan is one of the remaining four polio-endemic Afghanistan is one of the seven countries countries in the world. Afghanistan in WHO’s Eastern Mediterranean Region that has established well-functioning active has not eliminated maternal and neonatal surveillance for acute flaccid paralysis, tetanus. A recent WHO/UNICEF mission has and since 1998, successive rounds of identified 102 districts with uncertain risk for NIDs followed by sub-NID and mop-up maternal and neonatal tetanus that requires campaigns have been conducted. However, one round of TT immunization, while 101 due to insecurity in polio-endemic areas, districts were considered at high risk and implementation of such activities has been required 2–3 rounds of TT immunization. seriously affected and there has been a The estimated burden of diseases that resurgence of cases. In 2008, until mid could be prevented by new vaccines is
31 CountryCountry Cooperation Cooperation StrategyStrategy for for WHO WHO and andYemen Afghanistan high in Afghanistan: 36 000 deaths due to the last decades in Afghanistan and little is pnuemococcus, 15 000 deaths due to Hib known about the disease pattern in Afghan and 18 000 deaths due to rotavirus diarrhoea. society. With the assistance of GAVI, Afghanistan A study in 2000 compared the mental will introduce Hib vaccine as part of the health status of women living in Taliban- pentavalent vaccines (DPT/HepB3/Hib) in controlled versus non-Taliban controlled early 2009, and is expected to introduce areas. Major depression among women living other new vaccines in the near future. in Taliban-controlled areas was recorded as Outbreaks of epidemic-prone diseases 78% as against 28% among women living continue to occur in Afghanistan. In 2008, in non-Taliban controlled areas (Amowitz in addition to outbreaks of pertussis and 2003). Suicidal ideation was alarmingly measles, an outbreak of Crimean-Congo high–65% in Taliban-controlled area versus haemorrhagic fever and multi-focus 18% in the control area and actual suicidal outbreaks of cholera occurred. Avian attempts 16% in the Taliban-controlled area influenza has affected only poultry to date. In versus 9% in the non-Taliban controlled order to ensure early detection and response area. There has been no demonstrable to outbreaks, Afghanistan has scaled up the improvement in the mental health status of Disease Early Warning System (DEWS): 129 the population in the post-Taliban years. A sentinel sites in 34 provinces are functional. nationwide survey conducted in the first year Afghanistan has also started full adoption after the US-led invasion found high levels of of the International Health Regulations (IHR depression symptoms (male (59.1%), female 2005), along with their preparedness for (73.4%)), anxiety symptoms (male (59.3%), anticipated pandemic of influenza. A national female (83.5%)) and post-traumatic stress focal person for IHR has been nominated. disorder (male (32.1%), female (48.3%)) However, developing national preparedness and confirmed by others.11 There is a clear and response is still incomplete and will correlation between the number of traumatic remain a challenge. Laboratory support for events and the likelihood of developing disease surveillance is almost non-existent. psychopathology.
2.6.1.4 Noncommunicable diseases Anecdotal evidence indicates that cardiovascular diseases and cancer are Mental health remains an important being diagnosed with increasing frequency, problem. It is estimated that over 2 million but reliable estimates were not available Afghans suffer from mental health problems about their incidence and of the prevalence of such as depression, schizophrenia and related risk factors in the general population. bipolar disorder. Due to the long period of conflict it is estimated that most Afghans suffer from levels of stress disorder. Mental diseases have not been addressed over
11 Scholte WF et al. Mental health problems following war and repression in Easter Afghanistan. The Journal of the American Medical Association, 2004, 292:585-593.
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2.6.1.5 Emergency and humanitarian mandates and modus operandi for the health crises cluster. WHO country office capacity for emergency preparedness and response is The humanitarian situation in Afghanistan rather limited to deal with the leadership role has been deteriorating with the growing that has devolved on it and which includes insecurity and intensification of armed functions such as coordination at the central conflict that has spread northwards from the and provincial levels, training, joint planning south and southeast and with a dramatic rise and resource mobilization. Additional in the prices of wheat and wheat flour, and capacities in epidemiology, information crop failure in some regions. It is estimated and logistics would be required to deal that nearly 4.5 million people in both urban effectively with preparing for, and reponding and rural areas face greater food insecurity. to, humanitarian crises. The exact quantification and gegraphical location of the population groups most at 2.6.2 Provision of health risk is difficult to determine. Preliminary services and health system results of nutritional data collected in 11 performance provinces by the MoPH indicates increases The following sections address the in the global acute malnutrition rate (19.7%), provision of health services, hospital reform, in severe acute malnutrition rate in children governance and leadership, financing, the under the age of 5 years (6.7%) and in the health workforce, health information and severe malnutrition rate in 24% of lactating monitoring the performance of the health women and in 19% of pregnant women. system. In November 2007 a workshop was held in Afghanistan to discuss how the cluster 2.6.2.1 Provision of health services approach could support humanitarian In 2002, the MoPH decided to implement actions in the country. A humanitarian UN the provision of the BPHS through contracting Country Team (UNCT) was established at out to nongovernmental organizations. The the same time under the leadership of the cost of US$ 4–5 per capita was estimated Deputy Representative of the UN Secretary for BPHS as the basis for contracting. The General, the Resident Coordinator and the GCMU, which was established in the MoPH Humanitarian Coordinator. In early 2008, a in March 2003, is responsible for undertaking roll-out of seven clusters was started in a all steps related to the contracting out staggered process. WHO leads the health process, disbursement of funds, financial cluster with UNICEF, UNFPA and national and monitoring of contracts and supporting international nongovernmental organizations the three MoPH-strengthening mechanism as members. The MoPH is a key partner. provinces. It is estimated that 65% of the population lives within two hours walking The existing and potential crises in the distance of a centre providing BPHS. The country could fall under two categories MoPH is targeting 95% coverage to be (related either to civil strife and/or due achieved by 2015, which is also the year for to natural disasters) that imply different achievement of the MDGs.
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There are three major donors supporting A basic health centre is staffed with the contracting out of the BPHS: the World one nurse, a midwife and vaccinators, Bank (WB) in 11 provinces covered by eight covering a population of 15 000 to nongovernmental organization contracts 30 000 people. and three MoPH-strengthening mechanism A comprehensive health centre has contracts; USAID in 13 provinces based more staff than a basic health centre, on the cluster approach; and European including both male and female Commission (EC) in 10 provinces. For doctors, male and female nurses, comparability and as a trial for future midwives, and laboratory and pharmacy sustainability three provinces, assigned to technicians. It covers a population of 30 the WB—Kapisa, Parwan and Panjsher— 000 to 60 000 people. for implementation of the BPHS have been A district hospital (first referral contracted out to the MoPH strengthening hospital) serves up to four districts mechanisms. Staff are recruited through the and a population of 100 000 to 300 MoPH priority reconstruction and reform 000 people. It is staffed with doctors, (PRR) process, the selection is merit-based including a female obstetrician/ and the level of remuneration is almost three gynaecologist, surgeon, anaesthetist times that of the regular staff of the MoPH, and paediatrician, midwives, laboratory but considerably less than the salaries of and X-ray technicians, pharmacist, and the staff working in the nongovernmental a dentist and dental technician. organization contracted out facilities. Payment exemption strategies for the poor The BPHS is offered at four standard levels are implemented throughout the country within the health system. with different mechanisms. Meanwhile, A health post is staffed with one female the public health interventions and clinical and one male community health worker care (immunization, maternal delivery, covering a catchment area of 1000 to antenatal care, family planning, treatment 1500 people, equivalent to 100 to 150 of tuberculosis and nutrition interventions) families. are provided free of charge to any citizen of Afghanistan. User fees are charged at most
Table 4. Changes in the extent of access to primary health care services since 2000
Results 2000 baseline Achievement by High Health and 2006 benchmark Nutrition 2010 Strategy HNS 2013 Access to 9% of 65% of 90% of 90% of primary health population population population population care services within two hours walking distance
34 Country Cooperation Strategy for WHO and Afghanistan public health facilities, which is currently five to objectively assess the impact of Afghanis. Table 4 shows the change in extent training traditional birth attendants on of coverage since 2000. reproductive health outcomes. The cost of providing BPHS should be The experience of contracting out of the recalculated. BPHS to nongovernmental organizations Clearly, there were some tensions has been promising in the medium term, between the nongovernmental although there have been several issues in organizations and the provincial health relation to insufficient coverage, poor quality, departments. WHO could help in inequity and sustainability as the funding for improving coordination between the this initiative comes entirely from the donors. two through assisting the MoPH in The MoPH is keen to continue the policy of defining clear roles and responsibilities contracting out over the next five years. for the provincial health departments. The CCS mission had an opportunity to 2.6.2.2 Hospital reform meet with some of the nongovernmental organizations that had been contracted out The MoPH has conducted a national to deliver BPHS in some provinces in the hospital assessment in 2003, which helped country. Some of the issues that emerged identify the following priority needs. from this highly interactive meeting were as The ratio of 1 bed for 1000 was not follows. reached in any province of Afghanistan, WHO should actively engage with the including Kabul, and their distribution nongovernmental organizations as was uneven with large parts of the they are the provider of the BPHS in all population unable to access referral the provinces, except three, that are facilities. being managed by the MoPH and help The physical infrastructure was build their capacities in areas such as acceptable but hospitals lacked mental health, dealing with disabilities, adequate supply of water and electricity disease outbreaks and in responding and were under-equipped with to humanitarian crises that occur in improper maintenance. the geographical areas where they are Hospitals were under-utilized with providing BPHS. average occupancy rates below 50%. WHO should be more involved in ensuring Many hospitals, particularly in the equitable access to quality health care. large urban areas are over-staffed, Nongovernmental organizations should lack female staff and there is lack of be provided with health promotional management and clinical skills among and learning material produced by hospital staff. WHO and be invited to participate in The availability and delivery of various training activities sponsored by emergency obstetric care was WHO in Afghanistan. particularly insufficient and the referral In remote and poorly accessible system was weak. areas, consideration should be given
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Box 1. Strategies for improving health system performance and health outcomes Reducing morbidity and mortality Implement the BPHS Implement the EPHS Improve the quality of maternal and reproductive health care services Improve the quality of child health initiatives Strengthen the delivery of cost-effective integrated communicable disease control programmes Establish prevention and promotion programmes Promote greater community participation Improve coordination of health care services Strengthen the coverage of quality support programmes Reduce prevalence of malnutrition and increase access to micronutrients.
Institutional development Promote institutional and management development at all levels Strengthen health planning, monitoring and evaluation at all levels Develop health care financing and national health accounts Strengthen human resource development, especially of female staff Strengthen provincial level management and coordination Continue to implement priority reform and restructuring Establish quality assurance Develop and enforce public and private sector regulations and laws
In response, an EPHS has been prepared, Nutrition Sector Strategy 2008–2013 of which aims at standardizing hospital services. the MoPH provides the strategic directions Currently, most of the secondary and tertiary for tackling these challenges. Earlier, the hospitals are managed by the MoPH while MoPH, in consultation with officials of some are supported by donors (USAID five the Government of Afghanistan, external provincial hospitals; EC four provincial or donors, United Nations (UN) agencies and regional hospitals) or by nongovernmental other stakeholders, adopted 18 strategies organizations. for reducing mortality and morbidity in the country and for institutional development in The reform process in the hospital sector health (Box 1). This section will provide an was initiated with the implementation of analysis of the various health system building EPHS in eight provincial hospitals, for which blocks and their contribution to improving US$ 10 million has been allocated by the health system performance. Government to improve hospital services. The MoPH will have full ownership of this 2.6.2.3 Governance and leadership project and the proposed approach will The MoPH, with the assistance of its encourage other partners in the health sector development partners, has made considerable to engage in the hospital reform process. progress during the last six years in assuming The answer to many of the challenges its legitimate role as the steward of the health for achieving better health of the Afghan system. Several policy and strategy documents people reside in improving the performance have been developed with the assistance of of the health system. The Health and development partners. The most recent is
36 Country Cooperation Strategy for WHO and Afghanistan the Health and Nutrition Sector Strategy for health regulation and enforcement the period 2008–2013. Transforming these promotion of equitable access to health policies into strategic plans and implementable services programmes continue to remain a challenge. health workforce policy, production and management Efforts have been undertaken since 2004 quality assurance in personal and to restructure the public health sector at population-based health services the level of the MoPH and the provincial public health research, and health directorates to confront the health reducing the health impact of challenges. A renewed effort is underway emergencies and disasters. in 2008 to further reorganize the MoPH and provincial health departments so that 2.6.2.4 Financing the organizational structure is aligned to their functions, that there are clear Data on health care financing are scarce, departmental responsibilities and individual particularly in relation to spending by post descriptions, and that overlap among households. In the absence of a national various tasks and functions is minimized. health accounts analysis, the WHO Considerable technical support shall be estimates and studies carried out by donors required in the coming years to develop the and nongovernmental organizations indicate capacity of key directorates/departments, that the Afghan health care system is under- such as health policy and planning, health funded with a high level, up to 70% share of legislation and regulation, health human out-of-pocket spending. A survey conducted resources and health information. The by a John Hopkins University team found health sector in Afghanistan relies heavily that, within the catchment areas of health on financial and technical support from facilities, out-of-pocket expenditure by international development agencies, which households was up to US$ 29 per capita. requires good coordination. A strong The financing of the health system relies international health department in the MoPH mainly on contributions from donors (up is essential to efficiently undertake this to 60%, possibly more) channelled for responsibility. contracting out of the BPHS to national and The overall governance function of the international nongovernmental organizations health system is weak and systems need to and for the MoPH strengthening mechanism be in place to promote equity, accountability, and through funds to support the MoPH’s transparency, ethics, enforcement of regular budget. The per capita spending by regulation, and informed decisions. Particular the Government on health is estimated as attention and institutional mechanisms are 0.6% of GDP, which is passed on from the needed in the areas of: Ministry of Finance (MOF). In 2007, the MOF- approved projects were worth US$ 93.0 monitoring, evaluation and analysis of million, which comes to less than US$ 4.0 the health situation per capita public spending on health. public health surveillance health planning and management
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Health care financing constitutes one of attention. There is a continued shortage of the major challenges facing health system qualified health professionals in terms of rehabilitation and development, particularly numbers, gender, quality and distribution at as the Constitution mentions the right to all levels of the health services, especially ‘free’ health care. The concerns are the low for nurses, midwives, pharmacists and level of health expenditure, equity in access environmental hygienists. There is a to health services and sustainability of health continued severe shortage of female health care financing. The level of spending on workers in the remote areas of the country. health will remain low in the coming years There is maldistribution of health care unless high economic growth is expected. providers between and within provinces, and The financing gap should continue to be between urban and rural areas which leaves filled from donors’ contribution but a scheme the peripheral health facilities and remote has to be developed in terms of gradual areas understaffed. The main reasons for the disengagement by donors and take over by maldistribution are the poor working, living nationals. and social conditions, security concerns and lack of educational facilities for children and The Health and Nutrition Sector Strategy transportation. advocates for increased allocation to health. The spending should be: in line Since 2002, the MoPH has made major with priorities and coordinated across strides in building the human resources sectors; transparency strengthened in development process through establishment the allocation of financial resources and of the Directorate of Human Resources financial management; different sources of Development with all its important functions funding coordinated; monitoring the cost- at the central level; development of a national effectiveness of different mechanisms of policy for human resource development; financing of health care monitored; and rehabilitation of training institutions; updating relevant baseline information obtained, the nursing and allied health curricula; including on household expenditure on setting admission standards; refurbishing the health. educational institutes; developing teachers capabilities through in-service education; 2.6.2.5 Health workforce developing the community midwifery Afghanistan lost many health professionals programme; building the capacity of health during the 20 years of civil strife and workers; establishing a database for human conflict. Training facilities were destroyed resources for health; and establishing a and degraded; ad hoc training with varying testing and certification process to protect curricula, duration and teaching methodology the health of the public. was carried out within the country and The total health workforce in 2006 was across the borders resulting in different estimated at 27 340 health personnel, about levels and standards of health workers. The 10 500 of whom are working with contracted human resource development situation in nongovernmental organizations. The total Afghanistan is complex and requires special number of staff working at the MoPH is
38 Country Cooperation Strategy for WHO and Afghanistan estimated at 16 840. This includes 3704 of 12 years of schooling in order to be physicians, 3311 nurses and midwives, 3217 employed by the MoPH, this causes a major allied health personnel, 1836 administrative problem of recruiting clinically competent staff and 4762 support staff. Females health workers in remote areas. constitute 21% of the workforce. There are six medical schools in the country with Kabul 2.6.2.6 Health information Medical University as a main producer of A basic health management information physicians and dentists. There are currently system (HMIS) exists, which covers almost 8000 medical students enrolled in the 1450 health facilities that fall under the medical schools in Afghanistan. In addition, contracting out arrangements. Monthly there are nine Institutes of Health Sciences reports are sent to the provinces; data that prepare nurses, midwives and allied are entered on customized software and health professionals. Currently, there are forwarded to the central HMIS Directorate. 3500 students enrolled in these institutes. The main monitoring instruments are the: 1) The community midwifery programme facility status report; 2) notifiable diseases started in 2002; the programme is running report; 3) monthly integrated activity report; in 21 provinces with 640 students enrolled; and 4) monthly aggregated activity report. 140 community midwives have graduated There are concerns with the quality of since the establishment of the 18-month reporting, provision of feedback and the use programme. According to the MoPH’s of information for decisions. WHO support is strategic plan there is a need for 7000 needed for increasing the analytical capacity physicians, and 20 000 nurses, midwives at the central level and for providing hardware and allied health personnel to implement and supporting training at provincial levels. the BPHS, EPHS and other services. A The disease surveillance component of the human resources database has been set HMIS requires strengthening, with a view to up and registration of health workers has eventually integrating existing vertical single commenced, this will act as the basis for disease surveillance systems. Currently, future licensure of health workers. there is no programme for establishing a system of vital statistics in the country. Concern has been expressed regarding the level of knowledge and skills of health 2.6.2.7 Monitoring health system workers trained outside the government performance health system. A process of testing and certification has been set up, which shows The Balanced Scorecard (BSC) has been that on average 70% of nurses, midwives, the principle instrument for monitoring laboratory technicians and pharmacy health system performance instead of the technicians fail to achieve the minimum national HMIS. Its purpose is to summarize standards and require extensive retraining the performance of provinces in the delivery and 50% of the applicants have fake of the BPHS and to provide policy-makers, certificates. Of those achieving the required health managers and other decision-makers standard of professional competence, most with evidence on areas of strength and do not meet the old government requirement weakness. Three rounds of BSC monitoring
39 CountryCountry Cooperation Cooperation StrategyStrategy for for WHO WHO and andYemen Afghanistan of BPHS have been completed in 2004, sites across the country that provides 2005 and 2006. The comparison of results information of epidemics and outbreaks between 2004 and 2005 indicate a 12% many of which are managed at the provincial improvement among performance-based or district level. The laboratory backup for the partnership agreement (PPA) provinces.12 diagnosis of epidemics needs considerable a 10% improvement in performance-based strengthening. partnership grant (PPG) areas (USAID), an 8% improvement for strengthening mechanism 2.6.3 Challenges and priority areas provinces.12 and a 3.5% improvement in for improvement EC-supported provinces for the delivery of The challenges and priority areas for the BPHS. Other areas/facilities not covered improvement include: by any of the above showed a 3% decrease insecurity and lack of transport in performance. The BSC is a useful tool infrastructure that restricts people from for monitoring health facility performance, seeking health care, limits referrals of however, many of the indicators are process- cases to secondary care facilities and oriented and do not depict service coverage prevents health workers from working in or outcomes, it requires sophisticated the security compromised and remote analysis (including multivariate techniques) and inaccessible areas. This challenge and the cost is high (estimated cost of is however outside the purview of the data collection annually is US$ 300 000). health sector. There is thus a concern whether it could be humanitarian crises, both man-made institutionalized as a regular activity of the and natural disasters. There was limited MoPH. Several health and related surveys capacity within the WHO country have been undertaken since 2003 that have office and in the Government for supported evidence-based decision-making. preparedness and response to these These include the Afghanistan national health types of disaster. resource assessment (ANHRA); the multiple high infant, maternal and under-five indicator cluster survey (MICS) 2003 and its mortality rates. re-analysis 2005; maternal mortality survey; malnutrition, particularly among young nutrition survey; national disability survey; children and women. national hospital assessment (2006, 2007 high burden of communicable diseases and 2008); national risk and vulnerability and the need to stop transmission of assessment (NRVA); national health service polio virus in the country. performance assessment (2004–2008); and lack of national capacities for health Afghanistan health survey (AHS) 2006. planning and management, especially The MoPH has established a Disease in the areas of governance, health Early Warning Systems (DEWS) with the care financing, human resource assistance of WHO. It has now 129 sentinel development, for monitoring, evaluation
12 World Bank. Targets and Indicators for MDGs and PRSPs: what countries have chosen to monitor. The Development Data Group, Development Economics Vice Presidency, July 2005.
40 Country Cooperation Strategy for WHO and Afghanistan and analysis of the health situation promotion of equitable access to health at central and especially so at the services. provincial level. quality assurance in personal and lack of appreciation of the role of social population-based health services; determinants of heath in the national public health research. context and of the need for intersectoral environmental health issues, particularly action for improving health outcomes. scarcity of portable water, lack of health regulation and enforcement. sanitation facilities.
41
Section 3
Development Cooperation and Partnerships: Technical Assistance, Aid Effectiveness and Coordination
Section 3. Development Cooperation and Partnerships: Technical Assistance, Aid Effectiveness and Coordination
The emergence of Afghanistan in 2001 as eligible through the Fund: (i) recurrent costs, a nation state brought with it considerable including salaries and non-project technical challenges in rebuilding the country’s assistance; (ii) investment activities and physical and institutional infrastructure, as programmes; and (iii) salaries for returning well as the human and social capital. The Afghans who were living abroad. The ARTF Afghans working relentlessly with the team is funded by Government revenue and of development partners have collaborated external resources earmarked for special over these years to put in place some projects, it is administered by the WB with institutional frameworks that have helped to a management committee consisting of the systematically guide national development, Asian Development Bank (ADB), the United including the health sector. These include Nations Development Programme (UNDP), the Bonn Agreement signed in 2001; its first the International Development Bank (IDB) Constitution in 2004; the National Health and the WB. Health and nutrition is one of Strategy 2005–2006; the National Health the 15 national priority programmes funded Policy 2005–2009 and the Afghanistan’s through the ARTF. Millennium Development Goals Report The funding for the ARTF goes into the 2005, Vision 2020. ‘Core budget’ and it is unique in supporting More recently and building on the recurrent and operational costs which success of the 2006 London Conference donors are normally reluctant to support. on Afghanistan, the Afghanistan Compact This is the case for the ARTF but also for was signed by the Government and the projects outside the ARTF funded by the WB International Community. The Compact and the ADB. For Afghanistan this strategy identified three critical pillars of activity is unique as donors are normally reluctant to covering: security; governance, rule of law fund recurrent and operational costs. and human rights and economic and social The funding requirement for health and development to which the international nutrition ranged from US$ 173 million in community committed itself to providing 2002–2003 to US$ 320.52 million in 2003– resources and support to realize the vision. 2004 and US$ 281.7 million in 2005–2006 The health and nutrition programme falls fiscal year. However, the funding allocation under economic and social development. for the last fiscal year was US$ 115.61 Following the development of the first million, leaving a funding gap of US$ 166.38 national development budget in the 2002– million. 2003 fiscal year, the ARTF was established The overarching priority of the health in 2002 to create a coordinated funding sector is to address priority health issues mechanism for financing priority expenditure through a universal coverage of BPHS for Afghanistan’s reconstruction. Three supported by a strengthened referral categories of expenditure were identified as
45 CountryCountry Cooperation Cooperation StrategyStrategy for for WHO WHO and andYemen Afghanistan network that links patients into hospitals services to about 23 nongovernmental that provide the EPHS). The largest chunk of organizations in 13 provinces. It provides health budget (28%) is spent on the BPHS, technical support to the BPHS-implementing followed by capacity-building of the MoPH agencies and capacity-building to MoPH and (17%) and improving the quality of hospital procurement services through Management services (EPHS).13 Sciences for Health (MSH). It, in addition, provides institutional support to the provincial 3.1 Key international aid and health directorate for monitoring the activities partners in health of the nongovernmental organizations Donor funds are used to finance all of the funded by USAID. USAID also works through major programmmes of the MoPH, including the health system strengthening project to the delivery of the BPHS, EPHS, programmes undertake surveys and research to assess aimed at controlling malaria, tuberculosis, the demand accessibility of the product and HIV/AIDS and other communicable diseases. use. The EC spending of about €36 million About 60% of the funding for the health and from 2007–2009 funds the BPHS in 10 nutrition sector comes from international provinces and the EPHS in four provinces aid, including the salaries of high-level working through 10 nongovernmental expert national advisers in the MoPH and organizations and supports the salaries of for provincial health directors (ANDS 2008– provincial health directors and capacity- 2013). There are still commitments by these building of the provincial health coordination on continuous support from 2008–2013. team. The WB with a lump sum grant of US$ 98 million to the core budget from 2003–2006 3.1.1 Bilateral and multilateral supports the BPHS in 18 provinces through partners 11 non-governmental organizations, health infrastructural development and salaries Although there are many donors that (HEFD). CIDA supports immunization and support the health and nutrition programme polio eradication to the amount of US$ 50 in Afghanistan, the three main donors are million through WHO (HEFD). JICA is active USAID, EC and the WB. Other notable in the area of vaccines and the immunization bilateral partners include JICA, CIDA, Italian programme. Saudi Arabia, Qatar, United Corporation, ADB, Organization of Islamic Arab Emirates and the OIC provide support Conference (OIC), WB funds flow to a bank in health infrastructure development. account held by the Ministry of Finance (MoF) and can then requested by the MoPH. 3.1.2 The UN system in Afghanistan Funds for contracting from USAIDS and the EC are overseen by the donor and directly Key agencies of the United Nations provided to the implementing agency. Systems with a presence in Afghanistan are United Nations Assistance Mission USAID spent about US$ 80 million from in Afghanistan (UNAMA), UNDP, UNICEF, 2006–2008 to support the implementation UNFPA, Office of the United Nations High of the BPHS through outsourcing of health Commissioner for Refugees (UNHCR), the
13 Afghanistan’s 2020 vision. Achieving the Millennium Development Goals. Kabul, Government of Afghanistan, 2005.
46 Country Cooperation Strategy for WHO and Afghanistan
World Food Programme (WFP) and WHO The goal of the first grant from Round 2 is to offers technical assistance to the Government develop the national health sector capacity for of Afghanistan. The UNCT has developed communicable disease control (with special two UNDAFs thus far. The first UNDAF reference to tuberculosis, malaria and HIV/ (2005–2009) was found to be ambitious and AIDS) by strengthening management and had little or no impact in Afghanistan because administrative functions of the MoPH, together of its very weak implementation. The second with building partnerships and developing UNDAF (2010–2013), considered to be of new mechanisms for technical support and more modest ambition, was launched in coordination. Implementation of this grant is October 2009. The three areas of support for 18 months worth US$ 3.1 million (from 1 are: stability/governance/human rights; food December 2004 to 31 May 2006). For Round 4 security/livelihoods and basic social services the Global Fund approved (July 2005) a second (education, health, water and sanitation). grant for scaling up Afghanistan’s response There is growing interest among the UN to tuberculosis control worth US$ 3.4 million. agencies to find out what agencies can do The goal of this grant is to detect 70% of the together using the UNDAF. expected pulmonary sputum positive cases and have a success rate of 85% in the areas 3.1.3 Others covered by DOTS. Direct beneficiaries from both grants will be the people affected by AIDS, 3.1.3.1 The GAVI Alliance tuberculosis and malaria with limited access For the allocation from GAVI per year in to health services; MoPH supervisors, BPHS millions of US$, see Table 5. health staff and community health workers; and the private sector. The total Afghan population 3.1.3.2 Global Fund for Malaria, will benefit indirectly from the improved control Tuberculosis and HIV/AIDS measures for AIDS, tuberculosis and malaria. The MoPH is the principle recipient of two GFATM administration is fully integrated within Global Fund grants for Afghanistan (Table 6). the GCMU.
Table 5. GAVI allocation per year in millions (US$) to Afghanistan
Funding Allocation per year (in millions of US$) sources Year of GAVI Year 1 of Year 2 of Year 3 of Year 4 of Year 5 of Total application implem- implem- implem- implem- implem- funds entation entation entation entation entation 2007 2008 2009 2010 2011 2012
GAVI 0.00 5.27 9.28 7.23 6.68 5.73 34.19
47 CountryCountry Cooperation Cooperation StrategyStrategy for for WHO WHO and andYemen Afghanistan
Table 6. The Global Fund-approved expected and newly applied budget for Afghanistan, 2005–2010
Rounds Status Budget (US$)
Year 1 Year 2 Year Year 4 Year 5 Total
R2 (integrated) Approved 3 125 605 0 0 0 0 3 125 605 (December (18 months) 2004) R4 Approved 1 027 891 1 358 835 1 067 114 0 0 3 453 840 (tuberculosis) (July 2005) R5 (malaria) Newly 7 825 177 9 268 157 6 895 432 4 665 645 3 577 305 32 231 719 applied R5 (HIV) Newly 3 674 717 2 684 908 2 715 210 3 081 961 0 12 156 796 applied R5 (health Newly 1 040 580 939 510 735 110 444 160 855 110 4 014 470 system applied strengthening) Grand total 54 982 430
3.1.4 Others 3.2 Aid effectiveness
There are over 35 international and The National Development Strategy national nongovernmental organizations 1387–1391 (2008–2013) is an MDG-based working actively in the Afghanistan health plan that serves as Afghanistan’s PRSP. It sector primarily implementing the BPHS is underpinned by the principles, pillars and under contractual services agreement benchmarks of the Afghanistan Compact and from the GCMU and the donors. They are it is the overarching strategy through which particularly useful in bringing health services the nation’s three key pillars are thoroughly to the areas where government officials and described with clear indicators and partners cannot access due to insecurity. benchmarks. In the spirit of the Afghanistan The nongovernmental organizations and Compact, the Government and international the provincial health team undertakes joint community commit themselves to improving monitoring when feasible but clear definition the effectiveness and accountability of of roles will help to ease the tension. Although international assistance. Health being a the nongovernmental organizations meet social sector has a clear policy and strategy monthly with the MoPH to report on their (2008–2013) which takes into account the activities, there is no validation of their claims MDGs, as well as the targets of the national and quality of rendered service because of strategy, thereby subsequently enjoying infrequent supervision and monitoring due to the assistance and the commitment to aid insecurity. effectiveness of the international community.
48 Country Cooperation Strategy for WHO and Afghanistan
3.2.1 National ownership commitments from its international partners to support the goals of the ANDS and improve The Afghanistan Reconstruction Trust predictability of aid flows, better planning Fund (ARTF) helps reinforce the national and effective management of priorities. budget in order to align the reconstruction programme with national objectives stated 3.2.5 Mutual accountability and in the national strategy and gives the partnership Government more control over the allocation The ARTF represents an attempt to of funds to development priorities. The ARTF promote the transparency and accountability provides a coordinated way for donors to of reconstruction assistance. In addition, support the Government of Afghanistan. there are various coordination mechanisms The funds are allocated and monitored using such as the consultative group on health national systems within the Ministries of and nutrition, joint donor missions, technical Finance and Public Health. advisory groups, etc. that meet weekly 3.2.2 Alignment to monthly to ensure that the activities of line ministries and nongovernmental The ANDS (2008–2013) and the Health organizations related to the identified and Nutrition Strategy (2008–2013) have priorities in the ANDS are implemented set goals and priorities with monitoring in accordance with the targets and goals framework to ensure that international in the monitoring framework. The GCMU assistance contribute to these goals. Most of helps to ensure effective and transparent the assistance is given to the implementation mechanisms to manage and oversee grant of the BPHS and EPHS which are the stated contracts. It is an important step into the national strategies for revamping the health direction of ownership and institutional sector. accountability. 3.2.3 Harmonization 3.3 Summary of key challenges and opportunities The Government has developed an aid effectiveness strategy, in line with the 3.3.1 Challenges Paris Declaration for Aid Effectiveness and Afghanistan’s international obligations. The key challenges include: Despite the improved alignment of partners reduced impact of the financial programmes with national priorities, there and technical support given by the is need to improve standardization of international community to Afghanistan approaches, procurement services, joint health sector due to continuous conflict programming and implementation, tools and in many parts of the country which guidelines in order to improve quality and hinders access. maximize resource use. insecurity which hinders development partners and the MoPH from effective 3.2.4 Managing for result monitoring and supervision of the performance of nongovernmental The Government encourages multiyear
49 CountryCountry Cooperation Cooperation StrategyStrategy for for WHO WHO and andYemen Afghanistan
organizations in delivering the BPHS 3.3.2 Opportunities and EPHS, resulting in differences in the quality of health services delivered The key opportunities include: in various districts. the determination and resilience of the the contracting out of the BPHS Government and the Afghan people to and EPHS to nongovernmental build a nation state. organizations that keeps the provincial the commitment of the Government health authorities off the centre stage and international community to the of health care delivery at provincial and Afghanistan Compact which ensures district levels in Afghanistan creating continuous financial and technical tension. support to the national development lack of uniformity or standardization of objectives, including national health approaches, expectations, procurement objectives. services, funding and reporting the existence of the various highly mechanisms among different donors articulate institutional frameworks such resulting in high transaction costs on as the ANDS (2008–2013), national the part of the GCMU, MoPH and the health policy and overall strategy nongovernmental organizations. for the Health and Nutrition Sector maintaining a healthy balance between (2008–2013), etc. that guide systematic per capital health allocation and the and focused development in the health expectations of the donors, MoPH and sector. the Afghan people at the district level the commitment of the Government to by the implementing nongovernmental the principles of the Paris Declaration organizations. and establishment of various weak capacity of the provincial health institutional mechanisms to ensure coordination team, particularly the compliance, such as the ARTF, the health staff of many of the implementing ANDS Oversight Committee and the nongovernmental organizations. Joint Coordination and Monitoring weak harmonization in programmatic Board which improves alignment support within the UN system. of donor programmes with ANDS lack of technical coordination/ priorities, aid coordination and national leadership among donors and ownership. implementing nongovernmental the defined implementation mechanism organizations. for the BPHS and EPHS reduces continuous loss of trained senior duplication and confusion on the field. health officers to the nongovernmental the growing interest in joint organization community due to better programming and implementation from conditions of service. the evolving UNDAF (2010–2013).
50 Section 4
Past and Current WHO Cooperation
Section 4. Past and Current WHO Cooperation
4.1 WHO cooperation overview nongovernmental organizations as the most competent and leading agency in 4.1.1 Background the health sector. Its technical support covers all regions in Afghanistan. It owns The basic agreement between WHO an extensive database on health manpower, and the Government of Afghanistan was facilities and health indicators related signed in January 1959. According to this to the country. It is playing a key role in agreement, WHO shall render technical coordinating many intercountry activities advisory assistance to the Government with neighbouring countries. Its capacity in which shall be furnished and received in resource mobilization at country level has accordance with the relevant resolutions been growing in the last few years. and decisions of the World Health Assembly, the Executive Board and other organs of the Not withstanding the above strengths, Organization. WHO shall consult with the WHO in Afghanistan has several Government the publication, as appropriate, weaknesses such as the lack of critical of any findings and reports of experts that technical expertise in some of the priority may prove of benefit to other countries and areas such as policy formulation and to the Organization. The Government will strategic planning in different aspects of provide all personnel, materials, supplies, health systems, emergency preparedness equipment and local expenses necessary and response to humanitarian crises, social for the technical cooperation, including and environmental determinants of health counterparts to long-term staff or short- and in mental health. There is also a need term consultants, and premises/facilities for to upgrade its leadership and coordinating technical activity in the Ministry. role in the field of maternal and child health. It needs to play a more active role The WHO office in Afghanistan was at the policy level for promoting intersectoral established with a minimal staff in the sixties collaboration for improving health outcomes. in Kabul but due to the prevailing unstable An analysis of the current technical situation in the country in the past, the office capacities in the country office in relation was moved to several locations to sustain to each of the identified strategic priorities technical support. Since 2002, the office is given in Section 6. Also, WHO is facing has been operating through a well-equipped difficulties in the recruitment of staff and is main office in Kabul and seven suboffices faced with high operational costs because covering the whole regions of Afghanistan. of the limited resources which is affecting 4.1.2 Strengths and weaknesses of negatively its delivery capacity, particularly WHO in Afghanistan at subnational level.
WHO has been recognized by the Government, different partners and
53 CountryCountry Cooperation Cooperation StrategyStrategy for for WHO WHO and andYemen Afghanistan
4.1.3 Major achievements 4.1.6 Main areas of focus
Strong alignment of strategic and It is envisaged that WHO collaboration operational plans with national priorities; will be more strategic and focused on fewer working relationships with national authorities priority areas, which will be an amalgam of and different partners; and the high global and regional priorities aligned with implementation rates of the programmes are national priorities. Increased emphasis will considered among the main achievements of be given to WHO’s role as a policy adviser WHO in Afghanistan in the last few years. and broker. Opportunities will be sought for increasing and strengthening partnerships 4.1.4 Challenges with other international and national agencies, It is obvious that the challenges which including nongovernmental organizations are facing the country as a whole such as working in the field of health. Innovative instability, security and violence will have approaches will be sought to increase the their direct implication on the way that the effectiveness of WHO support. Attempts organization is performing. In addition, it is will be made to ensure the utilization of the noted that the space for humanitarian aid knowledge and skills present in the country is narrowing. The evolving and emerging for WHO’s normative work. priorities, such as noncommunicable The WHO Representative’s Office through diseases and outbreaks of emerging the WHO Representative and his staff has diseases, are calling for better preparation to assist national authorities in practising by WHO to respond timely and effectively. its role of coordination of all health-related The need for more capacities in advocacy activities in the country. This could be made and resource mobilization has been noted to through establishing strong relationships be high. and information-sharing with all partners and 4.1.5 Lessons learnt stakeholders in the health sector.
Close relationships and strong partnerships WHO in Afghanistan has to make all facilitated WHO’s work in the last few years. possible efforts to be more visible in the It helped the office to deliver more effectively. country. It has to improve its image. A The cluster approach, although it imposes communication and advocacy strategy has more responsibilities on the office, has to be developed for this purpose. enhanced the appropriate role of WHO within Considering the large number of national the UN team. The inclusion of the 10% as and international nongovernmental allocation for security and operational costs organizations operating in the health sector in the proposals for funding has helped a lot of the country, the country office needs to in improving the performance of the office. engage with them on a continuing basis, especially with those nongovernmental organizations that have been contracted out to provide BPHS in the provinces.
54 Country Cooperation Strategy for WHO and Afghanistan
4.1.7 Core functions of WHO in Review and Planning Mission (JPRM) 2008– Afghanistan 2009 mainly because the two exercises had taken place back to back. As for input, it For carrying out WHO operations at was useful to link the strategic objectives the country level, four distinct functions of WHO with national priorities. The CCS have been identified. They include has captured comprehensively the most catalysing the adoption and adaptation of important national health indicators and technical strategies, seeding large-scale country profile. implementation; supporting research and development and monitoring health sector 4.2 WHO structure and performance; information and knowledge- resources sharing to provide generic policy options, The following sections outline WHO’s standards and advocacy; providing specific structure and resources. policy advice and serving as a broker; influencing policy, action and spending. 4.2.1 Structure and staff of the office and suboffices 4.1.8 Modalities of work The WHO country office in Afghanistan The above four functions will be achieved is run by a WHO representative, 20 through the ordinary modalities of work international professional staff, and more that WHO is following with other Member than 332 national staff serving on different States, such as assisting in policy advice, types of contracts. Approximately a quarter mobilizing different expertise, providing of the staff are in the main office in Kabul technical support to all health systems and and the remaining staff are distributed programmes, improving national capacities all over the country in seven suboffices through different means, and others. located in Mazar-i-Sharif, Jalalabad, Herat, However, in Afghanistan, WHO is more Kandahar, Faizabad, Kunduz, and Gardiz. prepared to adopt all necessary measures to However, it is to be noted that 62 national deal with the complex emergencies that the staff members, 96 national staff have Special country is facing. It will further strengthen its Service Agreement (SSA) contracts and 174 relationship with the MoPH, as well as other have Agreements for Performance of Work ministries and stakeholders who have a role (APWs). This indicates possible difficulties to play in health sector. of staffing in the near future. The number of 4.1.9 Critical review of previous female staff represents only 2.5% of the total CCS, its use, input and results staff (the organogram and staff are shown in Annex 1). Unfortunately, no systematic review of the last CCS was made as it was not planned. 4.2.2 Support from the Regional Apparently, it was not properly shared or Office and headquarters disseminated. However, it was partially The current support from both the used as a strategic agenda for the previous Regional Office and headquarters is scored operational plans in the Joint Programme
55 CountryCountry Cooperation Cooperation StrategyStrategy for for WHO WHO and andYemen Afghanistan as excellent. For emerging and unplanned 4.2.4 Sharing and using knowledge activities, the two levels are making all possible efforts to provide the required WHO is a knowledge-based organization support even with exceptional approvals in and the country office can play an enhanced some cases. In the last few years, there was role in a country such as Afghanistan in a very obvious growing trend to involve the sharing up-to-date knowledge related country office team in so many intercountry to public health and its practice and activities organized by either the Regional demonstrating its use at various levels in the Office or headquarters. The country office health system of the country. had been involved in several subregional 4.2.5 Office infrastructure and activities with many of the neighbouring equipment countries in areas such as polio, malaria, tuberculosis and HIV/AIDS. The current main office in Kabul is located on an area of 2500 m2 upon which a building 4.2.3 The biennial work plan of two levels has been constructed to The financial analysis of the biennium give approximately 1820 m2 office space. 2006–2007 showed that the total budget The office is well-equipped to meet the which was made available for the WHO requirements of the work. Computer facility, collaborative programme in Afghanistan networking connectivity, GSM access with amounted to approximately US$ 72 million, both the Regional Office and headquarters, out of which US$ 5.3 million were from the and other basic requirements have been regular budget (RB) and US$ 66.7 million installed. Proper filing, archiving and storage from other sources. In the current biennium, system for office assets are in place. approximately US$ 59 million have been The office is generally well-secured and allocated as of the end of October 2008. It is represents a good working place for the staff. expected that other resources may increase Some deficiencies in the security system from now until the end of the biennium in have been already identified and forwarded December 2009. The breakdown of the to the Regional Office for action particularly budget for the two biennia is shown in the armoured vehicles which are very critical Table 7. for field missions. The seven suboffices are being assessed.
Table 7. Breakdown of budget (US$) for 2006–2007 and 2008–2009
2006-2007 Total Programmes WR country office
Total working budget (RB) 5 261 000 4 529 000 732 000
Total working budget pogramme 79 022 174 78 677 705 344 469
2008-2009 Total Programmes WR country office
Total working budget (RB) 5 495 568 4 711 568 780 000
Total working budget programme 96 866 254 96 410 942 455 312
Source: CAMS
56 Section 5
Strategic Agenda for WHO Cooperation
Section 5. Strategic Agenda for WHO Cooperation
5.1 Introduction WHO with its limited financial contribution (as compared to donors currently operating in The strategic priorities given below are Afghanistan) to national health development based upon a careful analysis of the country’s is well placed to assume a major role in health and development challenges, the coordinating the various inputs and ensuring national and international response to harmonization between the agendas of these challenges and the gaps identified various donors and nongovernmental in the response to these challenges. It also organizations operating in the country. takes into account to the Organization’s own priorities, strengths and strategic WHO faces a special challenge as the plans as articulated in the Eleventh General lead of the health cluster to deal with the Programme of Work from 2006–2015 and humanitarian crises facing the country. in its Medium Term Strategic Plan for the 5.2 Guiding principles for WHO period 2008 to 2013. It was evident from the at country level discussions held with MoPH officials that in the period covered by the present CCS, The work of the WHO is guided by core greater emphasis will be placed on seeking functions, which are based on the WHO’s WHO support for policy formulation and comparative advantage. These are: strategic planning on a variety of pressing providing leadership in matters critical health issues. At the same time WHO to health and engaging in partnership support would also be needed for generating where joint action is needed; evidence for policy formulation and planning shaping the research agenda programmes for areas that currently lack and stimulating the generation, the required evidence for this purpose (e.g. dissemination and application of noncommunicable diseases, road traffic valuable knowledge; accidents, etc.) through carefully designed setting norms and standards and surveys/research studies. promoting and monitoring their implementation; The CCS Mission felt that the strategic articulating ethical and evidence-based priorities proposed below are in alignment policy options; with national priorities as set out in the providing technical support, catalysing National Development Strategy and with change and building sustainable the health and nutrition component of the institutional capacity; strategy. However, the situation regarding monitoring the health situation and harmonization of priorities and programmes assessing health trends. between the large number of donors operating and supporting the health sector in Afghanistan need further improvement.
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5.3 Mission statement of WHO 5.4.1 Health systems strengthening in the country based on the values and principles of primary health The mission of WHO remains “the care attainment by all peoples of the highest possible level of health” in the sense that The main focus of health systems “Health is a state of complete physical, strengthening based on the values and mental and social well-being and not merely principles of primary health care are: human the absence of disease or infirmity” as resource development; stewardship and enshrined in the WHO Constitution as one governance; the health information system; of the basic principles. The Organization and health care financing. aims at strengthening its technical and Strategic approaches include to: policy leadership in health matters, as well assist in the development and as its management capacity to address implementation of national human the needs of the country, including the resource development policy and Millennium Development Goals. WHO plan that would entail human resource country office provides technical support to development production, management, address the country’s priority health issues distribution, retention and accreditation. within the purview of WHO core functions assist in the strengthening of which relate to engaging and partnerships, stewardship and governance in shaping the research agenda, setting norms health of the MoPH and the provincial and standards, articulating policy options, health departments, in particular for catalysing change and assessing health overseeing, monitoring and evaluating needs. and auditing the performance of BHPH- 5.4 Strategic priorities and EPHS-implementing partners. assist in the development of a well- The strategic priorities include: health functioning and integrated health systems strengthening based on the values information system that brings together and principles of primary health care; all sources and provides the necessary social and environmental determinants information for informed decisions at of health and health equity; the control appropriate levels. of communicable and noncommunicable assist in establishing adequate and diseases; reproductive and child health; and fair financing of the health system that emergency preparedness and response. ensures universal access to essential health care and protects households against catastrophic health expenditure. assist in conducting health care financing studies, including the costing of BPHS/EPHS and national health accounts.
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assist in updating and implementing develop a health equity monitoring a comprehensive national medicines tool as part of the health information policy. function that allows comparison among assist in developing coordinating selected health indicators across the 34 mechanisms for collaboration with provinces of the country. private and other para-state health sectors, as relevant. 5.4.3 Control of communicable and noncommunicable diseases The strategic approaches shall promote development of a health system that Strategic approaches for the control of underpins the universal values of primary communicable diseases include to: health care that include enhancing health assist the implementation of the polio equity, universal health coverage, community eradication initiative to achieve the involvement and client centredness. interruption of transmission of polio virus throughout Afghanistan. 5.4.2 Social and environmental support the strengthening of routine determinants of health and immunization and national efforts for health equity measles elimination, maternal and neonatal tetanus elimination and the The main focus of social and environmental introduction of new vaccines. determinants of health and health equity support the scaling up of prevention, are the social determinants of health and treatment and care for tuberculosis, environmental determinants of health. malaria, leishmaniasis and HIV/AIDS. Strategic approaches include to: support the development of national provide evidence through knowledge capacity in preparedness and response synthesis, generation and dissemination to epidemic-prone diseases. the role of social and environmental assist the strengthening and integration determinants and the various pathways of the different disease-specific through which these influence health. surveillance systems. advocate for health in all policies and facilitate the collaboration with for emphasizing the importance of the global health initiatives on social and environmental determinants communicable diseases, such as GAVI of health and health equity in health and GFATM. policies and programmes. Strategic approaches in the control of promote intersectoral action for health noncommunicable diseases, including as a means to tackle the wider social mental health, include to: and environmental determinants and assist in defining the burden of disease inequities in health. Such action can be due to noncommunicable diseases, at the policy, programme and the grass- including mental health and road traffic roots implementation level. The latter accidents in Afghanistan. can benefit from the community-based initiatives experience of the Region.
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assist in finalizing the formulation include to: of a national policy, strategies and assist the capacity development of plans for addressing needs in mental partners in the health cluster so that the health and substance abuse and their health Cluster can prepare and respond implementation to health needs in emergencies timely and adequately. 5.4.4 Reproductive and child health assist the national capacity Strategic approaches in addressing development for emergency reproductive health include to: preparedness and response, so that the promote the Making Pregnancy Safer national authorities at different levels initiative through increasing access to, can prepare and respond to health and availability of, essential obstetric crises appropriately. care services. support the strengthening of the facilitate collaboration with national disease early warning system outbreaks and international partners that address through improving its quality and reproductive health in Afghanistan. expanding its geographical coverage. assist the development and use of an strengthen the humanitarian health advocacy and communication strategy information system by ensuring a to address social and cultural barriers functional communication network and against reproductive health. data analysis capacity at national and subnational levels. Strategic approaches in addressing child support the national capacity health include to: development so that the government assist in expanding the IMCI approach and other relevant partners would meet and in integrating it in other health- the required obligations under the IHR related interventions targeted at 2005 appropriately. children and women of childbearing age. support in developing the capacity of health personnel in prevention and control of maternal and child malnutrition.
5.4.5 Emergency preparedness and response
The main focus of emergency preparedness and response is emergency preparedness and the IHR (2005).
Strategic approaches in addressing emergency preparedness and response
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Implementing the Strategic Agenda: Implications for WHO
Section 6. Implementing the Strategic Agenda: Implications for WHO
6.1 Implications for the country Identify mechanisms to ensure office translation of CCS into operational plans. Table 8 outlines the strategic directions, Advocate CCS to national and main areas, status, challenges and international partners and use it as implications for the WHO country office in WHO’s input to shape the health Afghanistan. dimension of the UNDAF that is currently underway. 6.2 General implications for the Consider restructuring of the country office organogram of the country office based The following items are a list of the general on CCS and needs. implications/recommendations for the Address the frequent absences of staff country office. from the office due to different official Expand partnership development in reasons (rest and relaxation, in-country health and leadership role of WHO and international duty travels, annual under the expanding, often complicated leave). partnerships in the country. This will Review the role and optimal use of be facilitated by establishing strong seven subnational WHO offices. relationships and information sharing Make use of the identified priority with all partners and stakeholders in of social determinants of health as the health sector. a means to promote intersectoral Efforts will be made to engage with collaboration and assist the MoPH nongovernmental organizations/ in developing an available and high civil society operating in Afghanistan, level administrative structure for this especially those nongovernmental purpose. organizations that have been The CCS Mission has highlighted the contracted out to provide BPHS in the need to develop a comprehensive provinces. repository of all health-related data Develop a strategy for advocacy and (including reports of studies/surveys communication and ensure greater conducted or supported by the various visibility of WHO’s contributions stake holders) in the country office. to national health development This could then be placed on the making full use of the enhanced Afghanistan country office web site. media opportunities now available in Afghanistan. Improve the working environment (well- being and security of country office staff) under difficult situations.
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6.3 Implications for WHO notice, when such expertise is not available Regional Office and at the country level. Under Section 6.1 certain headquarters weaknesses have been identified in the country office to meet the needs of the strategic Increasingly WHO is being judged at the priorities defined in the CCS for 2008–2013. country level (especially in countries such WHO Regional Office and WHO headquarters as Afghanistan) by its technical expertise should take appropriate steps to fill these gaps located in the country and by its capacity to soonest by fielding high-quality experts both bring in high-quality expertise often at short for long-term and short-term assignments.
Table 8. Strategic directions for the country office
Strategic Main areas Status Challenges Implications directions
Health systems Human resource At the time of the Lack of Technical expertise to lead/negotiate with partners strengthening development, CCS Mission visit, expertise to and the MoPH in health systems development is based on the governance, the country office address the needed. values and health information was in a transition health system One long-term senior expert (international staff) on principles of system and period as one of in its entirety. health systems policy and planning is needed. primary health health care the longer serving One long-term epidemiologist for health information care. financing. staff dealing with systems who could also provide technical assistance health systems for emergency and humanitarian action (EHA) and was being strengthening national capacities to implement the reassigned. IHR is needed. Technical support for specific areas, such as health care financing, hospital management, national medicines policy and medical equipment.
Social and A new, but a very Limited Improving the knowledge/understanding of country environmental important area understanding office staff determinants of that could also and capacity The need for technical assistance (short-term) to health and health help in promoting at country assist the country office in working on each of the equity intersectoral office (and strategic approaches collaboration. all levels) at The need for technical support (national and short- present. term international) to expand Community-based initiatives to be used as an entry point for social determinants of health.
Control of Communicable Generally Polio Maintaining and scaling up the capacity on communicable diseases satisfactory, eradication communicable disease. and except HIV/AIDS. (achieving Utilizing the polio eradication initiative for scaling up noncommunicable eradication of EPI and surveillance activities. disease and Scaling up partnerships with international and maintaining national partnerships, including GAVI, GFATM and partnerships), multi/bilateral donors. strengthening HIV/AIDS (strengthening capacity)
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Strategic Main areas Status Challenges Implications directions
Noncommunicable limited capacity Limited Focus in areas of work (e.g. mental health, road diseases, and lack of capacity, traffic accidents and diabetes, and possibly cancer). including mental evidence in need of Series of short-term consultants for: mapping health “focus” (burden of noncommunicable diseases). Policy formulation; planning; training; and advocacy (resource mobilization). Partnership development for advocacy, fund raising and communication.
Reproductive and Limited capacity Improving Given the importance of this programme area it was child health despite the large capacity critical to upgrade country office capacity with a size of problem/ to regain long-term senior expert (international staff) on policy demand, no leadership and planning, supplemented with by national and strategic and role, develop short-term experts in different areas. comprehensive strategic Partnership development for strategic response to response to this response. R/HC including joint planning, advocacy, resource priority area mobilization and communication. (fragmented efforts by partners and government, ad hoc responses, etc).
Emergency Limited capacity Increasing Improving health cluster capacity in health crisis preparedness and although capacity for through coordination, joint planning, training, response (EPR) initiatives such as WHO CO to communication, and joint resource mobilization the health cluster show WHO’s Improving CO capacity with technical assistants (long approach have leadership and short-term and national) in different areas such started in EPR, as epidemiology, information, logistics, preparedness increasing and response. overall capacity of health cluster in health crisis
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