Countdown to 2015 In-Depth Country

Case Study: Afghanistan

Presented by: Nadia Akseer, MSc, PhD Candidate

University of TorontoHospital for Sick Children

Toronto, Canada

Main Objectives

• To conduct a systematic, comprehensive assessment of RMNCH, nutrition, and survival trends in Afghanistan in the 2001-2014 “post-Taliban” era

• To perform an analysis of RMNCH-specific health systems components, policies, and financial flows

• To determine key predictors of change in health service utilization

Data Sources: Household Surveys

Survey Year Coverage

Expanded Program on Immunization Census 2013 National & Provincial

National Nutrition Survey 2013 National & Provincial

National Nutrition Survey 2004 National

Afghanistan Health Survey 2012 National

Afghanistan Health Survey 2006 National

Multiple Indicator Cluster Survey 2010-11 National & Regional

Multiple Indicator Cluster Survey 2003-04 National & Regional

Afghanistan Mortality Survey 2010 National & Regional

National Risk and Vulnerability Assessment Survey 2011-12 National & Provincial

National Risk and Vulnerability Assessment Survey 2007-08 National & Provincial

National Risk and Vulnerability Assessment Survey 2005-06 National & Provincial

• National surveys

• Facility-based surveys: Balance Score Cards (2004 – 2013)

• Health workforce data (2005 – 2013)

• Telecommunications data: Mobile phone tower frequency/spread

• Security/casualties data: HMIS data from MoPH

Mortality Trends: MMR

• Target: Reduce MMR to 50% of it’s 2003 level (i.e. reduce to 529 per 100K live births) by 2015

• Result: MMR decreased from 1057 in 2000 to 402 in 2013

• Reduction of 62% between 2000 to 2013

• Afghanistan has achieved MDG5a

Source: UN-MMEIG, 2014

*Note: IHME reports conflicting results indicating increase in MMR (885 in 2013)

Causes of Maternal Death

18.6

46.0

9.4

6.0

13.5

15.0

9.0

12.0

13.5

3.0

21.2

13.0

14.7

5.0

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

IHME

WHO

Percentage

Hemorrhage Sepsis/other maternal infectionsHypertensive disorders Obstructed laborAbortive outcome Other causesOther direct causes

*Respective sample sizes are:

WHO n=63,585 (estimated for years 2003 to 2009)

IHME n=8,778 (year 2013)

Mortality Trends: U5MR, NMR

127.8

91.0

49.6

36.0

0

20

40

60

80

100

120

140

160

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015

Mo

rtal

ity

Rat

e p

er 1

000

Live

Bir

ths

Under 5 (IGME) Neonatal (IGME)Under 5 (IHME) Neonatal (IHME)

Target U5MR 64.0

Target NMR 24.8

Neonatal Cause of Death

Major causes of neonatal (1-27 days) and post-

neonatal death have not changed from 2001

to 2013:

Neonatal

• Preterm birth complications (29% vs. 28%)

• Intrapartum related events (23% vs. 29%)

• Infections including sepsis, meningitis, and tetanus

(20% vs. 23%)

Post-neonatal

• Diarrhea (24% vs 20%)

• Pneumonia (26% vs 28%) Source: CHERG, 2014

Nutrition

60.554.1

43.1

8.813.2

9.0

33.925.1 25.5

0

10

20

30

40

50

60

70

80

90

100

2004 2011 2013

Pre

vale

nce

(%

)

Year

Stunting Wasting Underweight

Sources: National Nutrition Survey, 2004, 2013. Multiple Indicator Cluster Survey 2010/11.

Trends in anthropometric nutrition outcomes, children 6-59 months

Food Insecurity

Source: National Nutrition Survey, 2013

.

Prevalence of food insecurity across provinces in Afghanistan, 2013

Coverage Inequity: Provinces

0

10

20

30

40

50

60

70

80

90

100

**D

eman

d fo

r fa

mily

pla

nnin

g sa

tisf

ied

*An

ten

atal

car

e (≥

1 v

isit

s)

*Ant

enat

al c

are

(4+v

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*AN

C b

y sk

illed

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er

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ne

on

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l te

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us

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lled

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irth

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ility

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iver

ies

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itia

tion

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asfe

ed

ing…

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lusi

ve b

rea

stfe

edin

g(0

-5 m

onth

s)

*Min

imu

mm

eal f

req

uen

cy

ǂB

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nta

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ǂM

easl

es

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eive

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itam

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ing

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last

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ont

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iarr

hea

tre

atm

ent

(OR

S)

**C

ares

eeki

ng

for

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um

oni

a

**A

ntib

ioti

cs f

orp

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mo

nia

*Im

pro

ved

dri

nki

ng

wat

er s

ou

rces

*Im

pro

ved

sani

tati

onfa

cilit

ies

%

Pregnancy Birth Postnatal Infancy Childhood Water and sanitation

Pre-Pregnancy

Median national coverage of selected interventions**MICS 2010,*NNS 2013 & ǂEPIC 2013 • Provincial Coverage (%)

Coverage of interventions varies across the continuum of care

Health Systems & Policies

High-impact initiatives

• Implementing the Basic Package of Health Services (BPHS)

• Adapting the contracting-out mechanism

• Implementing a standardized national salary policy to motivate health care workers to work in rural areas

• Implementing national programmes (EPI, Malaria, TB, HIV/AIDS, CBHI, Nutrition, etc.)

• Training midwives

• Implementing the Essential Package of Health Services (EPHS)

Essential health system factors

• Strong stewardship by Ministry of Public Health

• Effective coordination and communication

• Regular monitoring

• Health management information system

• Health system performance assessment and facility surveys (Balance Score Cards) conducted through 3rd-party mechanisms

Health Systems & Policies

Health Workforce

Source: HR department, MoPH Afghanistan

2682

10973

14330

1893919648

21227

2336325478

28837

2005 2006 2007 2008 2009 2010 2011 2012 2013

0

5000

10000

15000

20000

25000

30000

35000

0

1000

2000

3000

4000

5000

6000

7000

8000

9000

10000

CH

W (

Freq

uen

cy)

Oth

er H

W C

adre

s (F

req

uen

cy)

Community Health Workers MD Specialists MD Generalists Nurses Midwives

Lives Saved Tool (LiST)

• Over 85% of all deaths could be averted by scaling up all intervention packages to 90% coverage level by 2025

– Approx. 135,000 deaths averted annually

– 84% of neonatal, 92% of post-neonatal, and 89% of maternal deaths

Lives Saved Tool (LiST)

• Most high impact: + 50% in EmOC and immediate newborn care ~9,900 newborn lives saved

• + 90% ~30,900 newborn/4,400 maternal lives saved

• Universal coverage of immunization 30,700 child deaths averted annually

• Water, hygiene, and sanitation interventions scaled up by 75% from current levels 16,100 child deaths averted

• Infant and young child feeding programs scaled up by 25% from current levels ~12,100 post-neonatal lives saved

Key Findings

• Afghanistan has made remarkable progress over a decade, but vast subnational inequities remain.

• Donor support, strong stewardship, effective health policy frameworks, improved access to care, and increases in skilled health workers contributed to success

• Further reductions in under-5 mortality require substantial investment in newborn care and in interventions to target stunting

• Contextual factors, including education and infrastructure(communication and transport systems), and health system strengthening are critically important

The Way Forward

Afghanistan must focus on

• increased investments in social determinants of health

• interventions to address newborn survival

• Strategies to reduce health inequities

Afghanistan Case Study Research Team

Nadia Akseer, MSc, PhD (Candidate)

Ahmad S Salehi, MD, MSc, MBA, PhD (Candidate)

S M Hossain, MD, MPH, MBA

M Taufiq Mashal, MD, PhD

M Hafiz Rasooly, MD, MSc

Zaid Bhatti, MSc

Arjumand Rizvi, MSc

Zulfiqar A Bhutta, MD, PhD