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Stronger health systems
Greater health impact
Dr. Mubarakshah Mubarak
Chief of Party Tech-Serve/MSH Afghanistan
Afghanistan Health System 2002-2010
Health Systems Building BlocksSe
rvice
deli
very
Health
wor
kfor
ceH
ealth
info
rmat
ion
syste
m
Med
ical
pro
duct
s, va
ccin
es a
nd te
chno
logi
es
Hea
lth sy
stem
s fin
anci
ng
Lead
ersh
ip a
nd g
over
nanc
e
Source: WHO
Afghanistan’s Broken Health System pre-2002
Weak health systems Inequitable distribution of health
services; clinics and hospitals damaged by war, earthquakes and neglect
Insufficient numbers of health workers, especially female
Poor data on health Chronic inadequate quality
drugs/damaged and outdated equipment
Inadequate finances Poor leadership and management;
little coordination among partners.
Poor health status Life expectancy: 47 for men
and 45 for women One in every four children
died before the age of 5 Maternal mortality
estimated at 1,600 per 100,000 live births, one of the highest ratios in the world.
4
Afghanistan U5MR and U5MR in the Region
0
100
200
300
400
1960 1990 2002 2006
Afghanistan
South Asia
The Ministry of Public Health Response
Stewardship role of MOPH: Contracting out to NGOs
Basic Package of Health Services
Community Focus
Rebuilding the system: Stewardship
Service Delivery: all services through NGOs
Health Workforce: capacity building included in NGO contracts; civil Service reform
Information: evidence-based decision making for policy formulation
Medicines/Vaccines/Technologies: centralized international procurement of quality/low price pharmaceuticals; few stock outs at facility level
Financing: by donors and government
Leadership & Governance: leadership development for NGOs and public sector
Increase of coverage to entire country
Rebuilding the system: BPHS
Service Delivery: expanded
Health Workforce: standardized staffing requirements
Information: standard indicators
Medicines/vaccines/technologies: limited set of essential
Financing: contracting all BPHS out via NGOs
Governance & leadership: close coordination between NGOs and MoPH/partners
Reduce maternal and child mortality
Rebuilding the system: Community focus
Service Delivery: Defined/focus TOR for CHWs
Health Workforce: 21,000 CHWs ( male and female)
Information: use of community maps; pictorial tally sheets; linked to HMIS
Medicines/vaccines/technologies: CHWs provide DMPA and ORS/zinc, and cotrimoxazole
Financing: volunteers, non cash incentives
Governance & leadership: policy and Strategy, NGOs development on CBHC
Community as Foundation for Health
Moving toward and integrated health system system
Rebuilding the system
Results of improved health systems
• Increase in functioning health facilities:• Year 2002 - 496 • Year 2009 - 1780
•Increase in percent of facilities with skilled female health workers:• Year 2002- 24.8% • Year 2007 - 82%
Source: National HMIS of Afghanistan
11
Results of improved health systems
0
5
10
15
20
25
30
35
2003 2005 2006
% of pregnant women receiving care from a skilled provider
% of women delivering assisted by a doctor, nurse or midwife
Source: MOPH/Johns Hopkins Afghanistan Household Survey, 2006
Improvement in health systems metrics
50556065707580859095
%
Availability ofEquipment
Availability ofDrugs
Availability ofFamily Planning
2004 2005 2006 2007 2008
Results of improved health systems
Source: JHU Annual Report on BPHS in Afghanistan
257
165191
129
50
100
150
200
250
300
Under Five Mortality Rate (per1000 live births)
Infant Mortality Rate (per 1000live births)
2000 2004/5
Source: UNICEF and JHU Survey
Results of improved health systems
Challenges
High infant, child and maternal mortality
Quality of services Weak hospital sector Significant salary inequities High level of dependency
on international support. Insecurity
The things that mattered
Focus, focus, focus
Consistency in key policies
Bold leadership
Programmatic: use resources that are there
High value placed on monitoring