Healthcare in Afghanistan: Scenario and perspectives

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1 Healthcare in Afghanistan: Scenario and perspectives Introduction The Ministry of Public Health (MoPH), Afghanistan is in charge of healthcare governance in the country and endeavors to improve the health and nutritional status of the people of in an equitable and sustainable manner through quality HCSs Provision (HCSP) and the promotion of a healthy environment and living conditions along with living healthy life styles. In 2003, MoPH developed a set of cost-effective and high impact interventions called the Basic Package of Health Services (BPHS), that would be available to all Afghans with special focus on those living in remote and underserved areas. Later on, in 2005, the MoPH developed the Essential Package of Hospital Services (EPHS), which defined the role and services of the hospital sector, specifically for the district, provincial and regional hospitals and aims to reduce high maternal and childhood mortality rates. 1 The key donors that focus mainly on funding BPHS and EPHS and support the health and nutrition sector are- the USAID, the World Bank and the European Commission (EC). The main UN Agencies that support health sector are UNICEF, WHO, UNFPA, UNODC and UNAIDS. Also, the Global Alliance for Vaccine and Immunization (GAVI) and the Global Fund to Fight AIDS, Tuberculosis and Malaria provide substantial assistance to the health sector. Many other health stakeholders are supporting health sectors and they are governments like, Saudi Arabia, Italy, Germany, France, Spain, Iran, Pakistan, India, United Arab Emirates, Canada, Turkey, Turkmenistan, South Korea, Japan, USA, New Zealand, Estonia and Norway. 2 Afghanistan s young and fast-growing population serves as both a resource and a challenge. It has become one of the youngest countries in the world, with 60% of the population of an estimated 27.5 million under 20 years of age, and nearly 70% under age 25. With a population growth rate estimated at between 2.2 and 2.8% per year and low life expectancy during the

2 period of prolonged conflict, this youth bulge will keep growing for several years. These demographics offer important prospects for renewal and growth. However, the country remains hard-pressed to provide adequate, equitable, and sustainable health and education services to meet the growing demand, or to find ways of creating jobs for an estimated 400,000 new labour market entrants each year. In addition, life expectancy has risen from 42 years in 1990 to 49 years by Nevertheless, these outcomes remain well below averages for countries in even the lowest category of human development. Due to the Afghanistan s geography, there are many pockets of population that are beyond the reach of public health facilities. In addition, the movement of patients, especially women and children, and health workers is significantly restricted by road insecurity and in many places by cultural norms, combing to adversely affect maternal and child health. Capacity development for the provision of sustainable quality health services by government in all provinces requires coordinated collaboration of all partners, as critical services are also provided by NGOs and development partners. Afghanistan continues to experience deep poverty and inequality as well as one of the weakest human development outcomes in the world, ranking 175 out of 187 countries in UNDP s 2013 Human Development Report. GIRoA s most recent report on progress toward the Millennium Development Goals (MDGs), issued in 2010, suggests that positive developments are greatest in the areas of education and child and maternal health, but there is little prospect for the country to achieve most of the MDGs, even within the longer period through 2020 afforded to Afghanistan, as a late entrant into the MDG process.

3 Selected Health Indicators S.N. Indicator Afghanistan Mortality Survey, Infant mortality rate 77 per 1000 live births 2 Under 5 mortality rate 97 per 1000 live 3 Maternal mortality ratio (MMR) 372 per live births 4 Antenatal care coverage 68% 5 Deliveries by skilled birth attendants 34% 6 Full immunization coverage Not available MICS data is 7 Access to primary health services (within 1 or 2 h using normal mode of transport) keenly debated 90% (goal) The Strategic Plan for the Ministry of Public Health actionable directions- puts forth ten emerging 1. Improve the nutritional status of the Afghan population 2. Strengthen human resource management and development 3. Increase equitable access to quality health services 4. Strengthen the stewardship role of MoPH and governance in the health sector 5. Improve health financing 6. Enhance evidence-based decision making by establishing a culture that uses data for improvement 7. Support regulation and standardization of the private sector to provide quality health services 8. Support health promotion and community empowerment 9. Advocate for and promote healthy environments 10. Create an enabling environment for the production and availability of quality pharmaceuticals. 3 MoPH Strategic Plan.

4 Public Healthcare Delivery System Basic Package of Health Services (BPHS) The BPHS 4 are offered at four standard types of health facilities, ranging from outreach by Community Health Workers (CHWs), to outpatient care at basic health centers, to inpatient services at comprehensive health centers and district hospitals. At the community level, basic health services will be delivered by CHWs from their own homes, which will function as community health posts and have a catchment area of 1,000 1,500 people, which is equivalent to families. The BHC is a small facility offering the same services as a health post but with more complex outpatient care and covers a population of 15,000 30,000, depending on the local geographic conditions and the population density. The Comprehensive health center (CHC) covers a larger catchment area of 30,000 60,000 people and offers a wider range of services than does the BHC. There are seven healthcare elements of the BPHS and their components have been provided at a glance in the table below: S.N. Health Service Areas Components 1 Maternal and Newborn Health Antenatal care Delivery care Postpartum care Family planning Care of the newborn 2 Child Health and Immunization Expanded Program on Immunization (EPI) services Integrated Management of Childhood Illnesses (IMCI) 3 Public Nutrition Prevention of malnutrition Assessment of malnutrition Treatment of malnutrition 4 Communicable Disease Treatment and Control Control of tuberculosis Control of malaria Control of HIV 5 Mental Health Mental health education and awareness Case detection Identification and treatment of mental illness 4 A Basic Package of Health Services for Afghanistan. FINAL pdf

5 6 Disability Services Disability awareness, prevention, and education Assessment Referrals 7 Regular Supply of Essential Drugs Listing of all essential drugs needed The Essential Package of Hospital Services for Afghanistan The Essential Package of Hospital Services (EPHS) 5 has three purposes: (1) to identify a standardized package of hospital services at each level of hospital, (2) to provide a guide for the MOPH, private sector, nongovernmental organizations (NGOs), and donors on how the hospital sector should be staffed, equipped, and provided materials and drugs, and (3) to promote a health referral system that integrates the BPHS with hospitals. The EPHS puts forth all the necessary elements of services, staff, facilities, equipment, and drugs for each type of hospital in Afghanistan. The EPHS identifies the following elements for each level of hospital so that the inputs or resources needed at each level may be is well stratified and comparable: 1. Diagnostic and Treatment Services For Various Conditions 2. Diagnostic Tests 3. Staffing 4. Equipment And Supplies 5. Essential Drugs Health Infrastructure and Human Resource For Health Decades of war has dilapidated Afghanistan s health infrastructure and the country's capacity to deliver health services. There are nine types of Health Facilities at multi- levels of health care delivery, including the Health Post, Sub Centre, Basic Health Centre (BHC), Comprehensive Health Centre (CHC) mentioned above. Additionally, there are: 5 The Essential Package of Hospital Services for Afghanistan FINAL pdf

6 - Comprehensive Health Centre plus (CHC+): This type of health facilities aim to provide maternal health care services particularly Comprehensive Emergency obstetrics Care services. These facilities have 10 beds. - District Hospital (DH): At the district level, the DH will handle all services in the BPHS, including the most complicated cases. The hospital will be staffed with doctors including female obstetricians / gynaecologists; a surgeon, an anaesthetist and a paediatrician; midwives; lab and X-ray technicians; a pharmacist; and a dentist and dental technician. Each DH will cover an approximate population of 100, ,000 people in one to four districts. - Provincial Hospital (PH): The PH is the referral hospital for the Provincial Public Health (PPH) Care System. In essence, the PH is not very different from a DH: it offers the same clinical services and possibly a few additional specialties. In most cases, the PH is the last referral point for patients referred from the districts. In some instances, the PH can refer patients to higher levels of care to the regional hospital or to a specialty hospital (SH) in Kabul. - Regional Hospital (RgH): The RgH is primarily a referral hospital with a number of specialties for assessing, diagnosing, stabilizing and treating, or referring back to a lower level hospital. The RgH provides professional inpatient and emergency services at a higher level than is available at DHs and PHs, yet the overall objective remains the reduction of the high MMR, IMR, and U5MR, and of other diseases and conditions responsible for Afghanistan s high mortality and morbidity. - National Hospitals (NH): NHs are referral centers for tertiary medical care and are located primarily in Kabul. They provide education and training for HCWs and act as referral hospitals for the PHs and RgHs. The ratio of health workers to population is 1.08 to Female workers make up 28% of the workforce (including unqualified support staff). Other than 100% midwives and 50% community health workers being female, only vaccinators and university educated groups of doctors,

7 dentists and pharmacists have about 20% female. There are 16.7 public health workers (including unqualified support staff) in rural areas, compared with 36 per 10,000 in urban areas. Most qualified private health workers are in urban areas. Only 22.6% of the population lives in urban areas, and most provinces are 90% rural. 6 Community Level service provision Is through Family Health House scheme. There is a qualified Community Mid wife, which provides basic package as well as conduct delivery. She also have support from Community Health workers in her area as well as have Health Shouras, kind of village councils for supporting health activities. In addition there are mobile health units is most in accessible areas to provide services. The under-five mortality rate in Afghanistan has been reduced from 176 per 1,000 live births in 1990 to 99 in 2012, a 44% decrease. The infant mortality rate was also significantly reduced, from 120 per 1,000 live births in 1990 to 71 in There are improvements in the supply and utilization of the health services. For example, the number of births at health facilities increased from 6% in 2003, to 19% in 2005 and to 32.4% in and the percentage of facilities with female skilled health personnel (doctors, nurses or midwives) increased from 39% in 2004 to 76% in The utilization rate of antenatal care (ANC) and skilled birth attendance (SBA) has increased, respectively, from 31% and 24% (NRVA 2007/8) to 60% and 34% (AMS 2010). Despite these encouraging trends, Afghan mothers and children s mortality remains among the highest in the region. It is unlikely that the MDG4 target of reducing under-five mortality to 59 6 Afghanistan National Health Workforce Plan , LoLordo, A., Increase in skilled midwives saving lives in Afghanistan UNICEF(2008), Afghanistan s community midwives. Context and challenge: Insufficient resources, poor maternal health outcomes, political instability.

8 per 1,000 live births by 2020 will be attained. 9 According to the most recent global targets, 10 Afghanistan needs to reach an under-five mortality rate of 20 and a neonatal mortality rate of 10 by This would require an Annual Average Rate of Reduction (AARR) of 6.5% in the under-five mortality rate compared with the current rate of 2.7%. For neonatal mortality, the task ahead is even more daunting the 2011 neonatal mortality rate is 36, so the current AARR of 0.1% would need to increase to 5.2% in order to meet the target. Healthcare Financing and Insurance The out of pocket expenditure accounts for nearly three-quarters of all health spending (73.6%) whereas the central government financed around 5.6 percent (USD 84,148,093) of health expenditures in International donor funding accounted for the remaining 20.8 percent (USD 312,468,367) of total health expenditure. These direct out-of-pocket (OOP) payments made by households are extremely inequitable for the poorest households. The central government should consider increasing its role as health financier and enlist the private sector to take a more active role as well. Afghanistan s public and private insurance sectors are underdeveloped. An operational social health insurance scheme does not exist despite small-scale programs during the 1960s and 1970s. The role of private insurance providers and employers in the financing of health services is emerging but remains extremely limited. 11 As per the current Health Financing Policy document there is no community based health insurance implemented in the country Levels & Trends in Child Mortality Report 2012; Estimates developed by the UN Inter-agency Group for Child Mortality Estimation. Special provision was made for Afghanistan, which started the Millennium Development Goals process five years later than other countries and therefore has targets to be reached by 2020 rather than APR document [full citation needed]. 11 Afghanistan National Health Accounts with Subaccounts for Reproductive Health Health Financing Policy Islamic Republic of Afghanistan, Ministry of Public Health.

9 Private Health Care Sector: The MoPH's private sector policies and strategies facilitate the strengthening and growth of private health sector organizations and improvements in the quality of the health services and products they provide. A dispersed and uncoordinated private health sector will not be able to effectively deliver health services and will not be able to influence policies that are favorable for the overall growth of the sector which any strong sector and civil society aims to achieve. Minimum investment in facilitating the structuring of the private health sector has huge return on investment due to a coordinated approach in health services delivery, towards the joint health goals of the health sector. The private health sector has seen improvement on this front, through the creation and evolving of the Afghanistan Private Hospitals Association (APHA) and the National Medicines Services Organization (ANMSO). These associations serve as a reference point through which the MoPH could establish working relationships with all members of these associations. However, much more is needed. The MoPH seeks to increase the impact that private spending has on the health of the Afghan population by positively influencing the types and quality of services and products provided by private health organizations. Consequently, in recent years, the private health sector has experienced rapid growth. Currently, there are approximately 220 private hospitals, 100 private drug producers and importers, tens of private diagnostic centers, and around 20 private educational institutes actively involved in health service provision and production in Afghanistan. In addition, household health expenditures represent 73 percent of total health expenditures, of which 62 percent are spent at private health facilities. 13 Pharmaceutical Market In Afghanistan, there are legal provisions establishing the powers and responsibilities of the Medicines Regulatory Authority (MRA). The MRA is responsible to regulate the medicines system both in public and in private sector and as well as in the medicine system of NGOs and other government departments, but the enforcement of the regulations is very poor in the 13 National Health Accounts ; World Health Statistics, 2007, WHO.

10 country. In Afghanistan only pharmaceutical companies are registered, medicines are not registered. There are no legal provisions requiring the MRA to make the list of registered pharmaceutical products publicly available and update it regularly. Regulations exist to allow for inspection of imported pharmaceutical products at authorized ports of entry, but due to lack of human and financial resources the inspection at the ports of entry are often not performed. Legal provisions exist requiring manufacturers (both domestic and international) to comply with Good Manufacturing Practices (GMP), but currently the GMPs are required only for the International manufacturers and not for the domestic manufacturers, because the GDPA has not developed GMP for the manufacturers yet. 14 Key issues: The country faces high out of pocket expenditure for obtaining healthcare and has to address challenges in Human resources for health availability and deployment especially in conflict affected provinces. Given the growth trajectory in future and likelihood of increasing GOIRA revenues, public financing for health is likely to increase which can be optimally used for creating health infrastructure. The main source of essential medicines is the local market for private pharmacies and nongovernmental organizations implementing health programmes. Most of the essential medicines are imported from neighboring countries with little or no control. Afghanistan's capacity to certify imported medicine through quality control checks is weak. 15 The situation of healthcare in Afghanistan needs updated scoping and assessment for Private Sector involvement, capacity building and training of human resource for health, health information technology, health insurance and access to medicines & contraception. There is increasing recognition of need for MoPH stewardship and regulatory mechanisms for pvt health care sector. 14 Afghanistan Pharmaceutical Country Profile, Essential medicines and pharmaceutical policies; WHO Afghanistan.

11 Access to family planning services is still a challenge and this could reduce maternal deaths if contraception use reaches around 60%. Also factors like numbers of skilled birth attendants, reliable transport and availability/quality of emergency obstetrical care facilities vary greatly within Afghanistan, so there is a need to study and prioritize contextual interventions that will bring forth the evidenced impacts in attaining health. 16 Improving healthcare will require continued investments in developing technical capacity in health technology and access to medicines arenas; fostering cross learning of best practices with other developing countries; health infrastructure; a focus on improving health-worker performance through training, material support. Human Resources for Health is one major health systems component needs strengthening in a major way. Country needs to invest in setting up more medical schools and nursing/paramedical training centre, regulatory structures such as Afghan Medical and Nursing Councils as well as offering structured in service training programmes. Use of e learning plate forms for capacity building needs to be further explored. Afghanistan is one of the three polio endemic countries left. Though WHO has invested in establishing surveillance systems and mass vaccination drives, much more needs to be done in mobilizing support from community especially Taliban. Indian experiences in reaching out to resistance communities can be considered leading to fine tuning of outreach BCC strategies. 16 Carvalho N, Salehi SA, and Goldie JS. National and sub-national analysis of the health benefits and cost-effectiveness of strategies to reduce maternal mortality in Afghanistan. Health Policy Plan. (2012)doi: /heapol/czs026

12 Annexure: List of Key Indicators-Afghanistan Key Indicators Year & Data Source Total Population (million) 26,000, CSO Life Expectancy at Birth, males (year) AMS Total Fertility Rate AMS % Population with sustainable access to improved water AMICS source % Household using improved sanitation facilities AMICS % Population within one hour walking distance from a NRVA public health facility Total expenditure on health as % of GDP (2012) 8% 2012 NHA Out-of pocket expenditure as % of total health expenditure 73% 2012 NHA Government health expenditure as % total government 4.2% 2012 NHA expenditure ( ) No. of health facilities 2, HMIS No. of health posts 13, HMIS No. of PHC Center/ 10,000 population (2012) NHA No. of hospital beds / 10,000 population (2012) NHA No. of consultation per person per year 1,600, HMIS Total health personnel of public sector (2012) 24, HMIS Authors: Dinesh Agarwal and Raghavendra Madhu. The views expressed in this paper are entirely those of the authors and have been developed as a part of the, IPE Global. The note may be freely quoted or reprinted but acknowledgement is kindly requested.

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