WHO Afghanistan

The Bright Side

2003

The Bright Side 2

Polio Eradication 3

Expanded Program on Immunization 4

Water & Sanitation 17

Mental Health 18

Laboratory Rehabilitation 18

Primary Health Care 5

Stop TB 7

Health Action in Crisis 9

Basic Development Needs 11

Integrated Management of Childhood Illnesses 13

Maternal & Child Health 15

Roll Back Malaria & Leishmaniasis 16

Health Communication 19

Contents The Bright side …

Afghanistan is among theseven remaining polioendemic countries in theworld with Pakistan,India, Egypt, Nigeria

Niger and Somalia. In 2003 the polioeradication initiative in Afghanistancontinuedtobestrengthenedandgearedtomeettheglobaltarget by2005.

According to a study on locomotordisabilitiesinAfghanistanconductedin1997, under 15yearsofage havebeenmoredisabledby poliomyelitisthanbylandmines.

At the onset of 2003, the TechnicalAdvisoryGroup(groupofpolioexpertsfromUNICEF,WHO,CDC)drawingonthe successes achieved over the years,had targeted 2003 to interrupt thecirculation of the polio virus inAfghanistan.

The target was determined based oncommendable regular assessments ofSIAs in Afghanistan made byindependent groups . HoweverAfghan i s t an ’ s march towardseradicationwasjeopardizedthisyearbysporadic insecurity. Recent return ofrefugees from polio endemic areasoutsideAfghanistanincreasedtheriskofvirusimportation.

Afghanistan’s route to polio-freecertification is contingent on thefollowing factors which overall arenearingrequiredstandards.

The government authorities renewedcommitment and activeinvolvementinall SIAs coupled with the relentlessefforts by WHO,UNICEFandpartnersin the planning and implementation ofhigh-qualitykeystrategiesinSIAsandAcute Flaccid Paralysis (AFP)surveillance, is attributed to thenoteworthyreduction inthenumberofreported wild polio virus per year inAfghanistan.

Only7 polio caseshavebeenreported

to date in 2003. A tremendousachievementincomparison to the morethanahundredcasesafewyearsback.Ifthisdecreaseinthenumberofconfirmedpolioviruscasesissustained,itwillplaceAfghanistan among those countrieswhich will meet the global target oferadicatingthisvirus by2005.

This year inter-factional fightingincidencesinmanyareasofthecountryhampered access to children byvaccinationteams.

Neverthelessoverallpolioimmunizationcampaigns reached over 90% of thetargetedpopulationscovering morethan6millionboysandgirls,under5yearsofage.

The established surveillance system toidentify and reportallchildrenunder15yearsofagewithAFPhasimproved tosatisfy certificationstandards. In2003,thenumberofAFPsurveillancesentinelsites(healthfacilitybased)increased to410 covering 95% of districts inAfghanistan.

Community based AFP surveillanceinvolvesmorethan4thousandmullahs,teachers, village elders and other

populationgroups.

The AFP surveillance system is alsobeing used to report measles andNeonatalTetanuscases.WHOisnowintheprocessofintegrating otherdiseasesof national public health importanceincluding AEFIs (Adverse EventsFollowingImmunization).

AsofSeptember 2003therateofnonpolioAFPrate was 3.9 anincrease incomparisonto2002whoseratewas3.3.

As for specificity, this indicator ismeasured by the percentage of casesfromwhich2stoolspecimensaretakenwithin 14 days of onset paralysis(target:80%). In 2003 the rate ofadequatespecimen was 89% against80%in2002.

Thepolioteamhasestablishedasystemby where surveillance focal pointssystematically report to the Centrallevel.Thelatterconductsanimmediateepidemiologicalinvestigationinvolvingactive searchforanyotherAFPcases,travel history, vaccination status ofchildren intheareaetc.Onthebasisofthe investigation results additionalmop-up activities are plannedaccordingly.

Strong government andstakeholderscommitment

Observation of years ofzerowildviruspoliocases

Accessing children inremotestandconflictareas

A c h i e v e m e n t s i nsurveillance

Demonstrated capacity torespondtoemergencies

Polio Eradication

Q u a l i t a t i v eS u p p l e m e n t a r yImmunizationActivities

A wel l establ ishednetwork

In 2003, the Ministry of Healthc o n d u c t e d 4 r o u n d s of massimmunizationcampaigns(April,May,September and October), 2 rounds(March and July) of Sub NationalI m m u n i z a t i o n D a y s ( S N I D s )synchronized with Pakistan includingMop-uproundsasandwhenindicatedbythesurveillancedata.In2002,Fiverounds of NIDs were organized inaddition to two rounds of SNIDsimplementedinthecountrieshigh-riskprovincesofAfghanistan.

For every round of NIDs there is anetwork of more than 40 thousandvolunteers to provide poliovaccinetoAfghan children. Since 2002 theinvolvementofwomenvolunteers hasincreased. InJuly2003SNIDs morethan 3 thousand women volunteersactivelyparticipated.

In2003,about718caseswerereported,asofSeptember,ascomparedtomorethan8000 casesin 2001.

Nation-wide measlescampaigns were

organized to tackle the largest contributor ofmortalityamongstthesixpreventableEPIdiseasesinchildrenunderfiveyearsofage.

5.2millionchildrenbetween9-59monthsoldwerevaccinated with measles during a follow-upcampaignconductedinJune2003.Year2002sawsuccessful campaignssaving11.5million childrenwithadoseofmeasles.

More than750,000womenofchildbearingage(CBAs)werevaccinatedagainsttetanusthisyearduringmasssupplementaryImmunizationcampaign, achievingmorethan90%coverageintargetedcities.

In 2003 routine immunization coverage ratesincreased.AlthoughAfghanistanhasbeeninastateof complex emergency for over 20 years, basicimmunization services have been maintained withthe help of MoPH, WHO, UNICEF as well asgovernmental andnon-governmental organizations(NGOs).

After September 11, funds for EPI improveddramatically.Plansforutilizationoffundsinsevenselected provinces were elaborated duringconsultativeworkshops onEPI,inFebruary 2003,andlateAugust,toprovideimmunizationagainst6EPI target diseases: Tuberculosis, Pertussis,Measles, Diphtheria, TetanusandPoliomyelitis tochildrenunderoneyearofage,andTetanusamongwomenofchildbearingageinAfghanistan.

Theestablishment of a health infrastructure andcapacitybuildingwere amongthemajor gainsinthe expansion of the Routine EPI program inAfghanistan.

Polio eradicationhashe lped strengthenroutine immunization in all itsaspects,f r o m b u i l d i n g the l o c a l h e a l t hinfrastructure to the establishment ofmodels in disease surveillance, EPIstreamlining of data collection, timelyreport ing, analys is , provis ion ofappropriate feedback, capacity buildingand overall organizational setup andmanagement.

Developmentofa nationalEPIpolicyEstablishment of eighty-six new EPIfixed centers throughout the countrytaking the total to 642. Despite thisnumberofoperationalEPIfixedcenters,accessibility to EPI services remainlimited.Establishment and functional NationalEPI office at the Ministry level sinceOctober2002.StrengthenedcoordinationamongallEPIstakeholders throughanactivenationallevel Inter-Agency CoordinationCommittee(ICC)forEPI,establishedinSeptember2002.Functional Regional EPI ManagementTeams (REMTs) and Provincial EPIManagement Team( PEMTs) ensuringdecentralized implementation of EPIservicesthroughoutthecountry.

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Other SIAS

M a j o rAchievements2003

Prioritiesfor2004

Measles

Tetanus

RoutineEPI

In Afghanistan the PHC ispromoting functionalintegration of services andproviding guidance in thedelivery of Basic Services

(BSP).

Through this strategy WHO ishelpingcommunities dependent onexternal assistance assume greaterresponsibility by exploiting localresources to develop a sustainablehealthcaresystem.

Package

The BSP was strategically devisedt o reach the under - se rvedpopulations.TheMinistryofHealthorganizedastakeholdersmeeting,inJu ly 2003, t o f inal ize theimplementation modalities of theBSP. Itwasagreedthat NGOswillbe contracted out by aid agencies(WorldBank,USAIDandEuropeanUnion) throughPerformance-basedPartnership Agreements (PPAs) todelivertheBSP.

With support from WHO theministry of health conducted anational planning workshop wherenational prioritiesfor2002to2005were identified.

A National Policy Document thatprovides strategic direction of thehealth care system was produced.Theprogramsupportedtheministrytoundertakearestructuringprocessin which a functional organogramwas developed with clear lines ofsupervision, support and redefinedrolesandresponsibilities.

The programme supported thefinalization of MOH restructuringprocess:Anew organo-gram of theministry has been developed,missionstatementofeachofMOHdepartmentshasbeendefined;termsof reference for department and

u n i t s w e r e d e f i n e d a n ddepartmental structures havebeenredesigned.

Insupportto primaryhealth care,secondary and tertiary healthfacilitieshavebeensupportedwithessentialsuppliesandequipment.

In2003WHOsupportedMOHtoaddress the workforce imbalance,distribution, andthequalityofthehealth workforce to revitalize thehealth sector, and improve itscapacity to provide the adequatehealthservices.

230 Community health workersand provincialhealthmanagementteams (PHMTs) were trained onhealthmanagementandcontrolofDiarrhoeal andARIin10villagesof5provinces.

280 health professionals weretrained on district health caresystem and in PHC leadership,management and community-

basedhealthcaresystem

WHO awarded fellowships to over 50HealthpersonnelofMoHindifferent

FieldsofPublichealth

A national workshop on HumanResource Development (HRD) wasorganized in January2003,inKabu,ltoaddresstheexistingHRproblems.

In June 2003 WHO sponsored aworkshop on Medical education inAfghanistan.

BasicServicePackage

Nat iona l p lann ingworkshop

Policy development

Capacity building

H u m a n r e s o u r c edevelopment

Primary Health Care

Priorities 2004

Priorities for 2004

Na t u r a l a n d m a n - m a d edisasters(2002-2004) aswellasoutbreakofcommunicablediseases demand permanent

attentionandadditionalinvestmentsfromtheministryofhealthwithWHO’sclosetechnicalsupport.

The continuous return of refugees fromneighboring countries, the estimatedpresenceof500000IDPsinAfghanistan,the lack of access tohealth services formorethan30%oftheAfghanpopulation,and simply the present healthprofile ofthe Afghan population are issues thatrequire additional attention from theWHO.

Since 1998, earthquakes havekilled 19, 400 people. The most recentearthquakeoccurredinMarch2002intheNahrin d.istrict. An estimated 1200people were killed, 1800 housesdestroyedand5000madehomeless.

Naturaldisasters

InJune2003,sandstormslefthundredsofpeople homeless, destroyed crops andcontaminated water supplies of villagesin Lash Wa Juwayn and Shib Kohdistricts.

A pertussis outbreak, reported during thefirst week of January 2003, mobilized theinternational aid agencies to providemedicine andtakeappropriate measures toassist andtreatmorethan 40000children,and totrainvolunteersintheadministrationof drugs in Darwar district of Badakshanprovince..

Pertussis (whooping cough) is transmittedby direct contact with airborne dischargesfromtherespiratorymucousmembranesofinfectedpersons.Itcausessevere coughofseveralweeks'durationwithacharacteristicwhoop,oftenwithCyamopsisandvomiting.AnotheroutbreakoccurredearlySeptember2003inRaghdistrict inBadakshan.

Emergency activities were reactivated,during the first week of October 2003,following another upsurge of pertussis, inMandol district of Nooristan, under thecoordination of WHO. According to

assessmentteams,6villageswereaffectedand 36 people were reported to havesuccumbedtothedisease.

WHO conducted training on casemanagement and drug distribution tocommunity health volunteers and healthpersonneloftheMinistryofHealth.

The diphtheriaepidemicwasfirstnotifiedin Zhari Dasht IDP camp, Kandahardistrict, on June 28 2003, whereapproximately 35000peoplearesettled.To date 84 suspected cases have beenreported.Diphtheriaisabacterialinfectioncausedby

transmitted from person to personthrough close physical and respiratorycontact. Itcancausetheinfection of thethroat,which mayleadtoobstructionofthebreathingandcausedeath.

The first suspected Diphtheria caseswereadmittedattheIDPcampclinicrunby MSF-Holland then transferred totheInfectious disease ward (IDW) alsosupported by MSF-Holland in MirwaisHospital.

Outbreak control measures were soonafter implemented by a constellation ofaid agencies: Medecin Sans Frontiere ,Inter-SOS, IFRC spearheaded by MOHwiththesupportofWHOandUNICEF.

Thesemeasuresincludedactivetracingofpossible cases and their contacts,treatment of patients, recording offamilieswithmemberssuspected,orwithprobablediphtheria,designingofspecifictraining tools for health personnelresponsible for case finding and contactt r a c i n g , c a s e m a n a g e m e n t ,implementation of the surveillancesystemandtheorganizationoflargescalepulse immunization campaigns. Around24800peoplewereimmunizedwithDTandTDduringthe 1st.Roundand23700during the 2nd round in August andSeptember.Thevaccineswereflownintothe camp by WHO (4 million I.U ofdiphtheria antitoxin) and UNICEF (48000dosesofTdand24000dosesofDT).

Pertussis

Diphtheria

Health Action in Crises

Consolidation of theexisting areas

Re-organisation, maintenanceandtechnicalaswellasfinancialsupport of additional socio-economicactivitiesin Nangarharprovince.

Funding and maintenance ofdifferent community identifiedpriority schemes in Ghazniprovince;

Continuation and strengtheningof the BDN activities in fivecommunitiesof Herat province.

Strengthening of the BDNprograminFaizabad.

Expansion tonewareas

InitiationandfundingofBDN-approachbasedactivitiesinNangarhar,Kabul,Ghazni,andFaizabad

Achievements2003

Priorities for 2004?

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Rapid improvement of primary health care serviceswith positive changes in trends of mortality andmorbidity figures within a short period: significantchanges in literacy rates a n d sanitation status of theBDNareas

Increasedawareness of thecommunitythatitisboththe duty and the right of the people as individuals,familiesandcommunitiestotakeresponsibilityfortheirownhealth

Highlighted thepositiveeffectofBDNinterventiononpoor communities and increased motivation of morefamiliestohelpthemselvesforbetterqualityoflife

·UN and NGO partners in BDN are willing toparticipate in the implementation and evaluation ofactivities.

WHO partnerships expanded with developmentagencies, financial institutions, academic and civilsociety

Capacity for institutional and human resourcesdevelopmentstrengthened.

Basic Development Needs

Capacitybuilding

Organisation of multiple trainingworkshops (initial & refresher) forthe BDN inter-sectoral TechnicalSupport Teams (TSTs) and thecommunity management structures( V D C s , C R s , v a r i o u s s u b -committees,etc.)indifferentregionson the concept and implementationstrategyofBDN.

WHO Afghanistan has beena c t i v e l y p r o m o t i n gcommunity-based initiativesthat will contribute to the

progressive improvement of the social andeconomiclifeofthecommunities.The BDN initiative focuses on healthactivities and provides support to poorfamilies, particularly women, to achievebetterhealthandbetterqualityoflife.

ThroughtheBDNstrategy,WHOisgivingtheopportunity to thousands of women toparticipate in income generating activitiessuch as tailoring, carpet weaving, woolspinningandbakery.

In 1996, the Eastern Mediterranean RegionalOffice (EMRO) introduced the BasicDevelopment Needs (BDN) initiative, inAfghanistan, as a health strategy to address all

determinantsofhealth,tosupportindividuals,familiesand communities toattain self- sufficiency and self-reliance through an integrated and comprehensivedevelopmentscheme.

TheBDNapproachimprovespeople'squalityoflifeinAfghanistan through:

awarenessraisingamongcommunitiesaswellasthegovernmentauthoritiesonself-help,self-managedandself-sustainableschemes forbetterqualityoflife;

promotionof participatory approachesinintegrated

socio-economicdevelopment;

development of entrepreneurships with thecommunityforsustainabledevelopment;

encouragement of inter-sectoral action among linedepartmentstosupport health;

Advocatingforhealthasthecorestrategyforhumandevelopment.

WHO Afghanistan BDN projects have reached 22villages spanning over 6 provinces (Kabul, Bamyan,Nangarhar,Ghazni,HeratandBadakhshan)withatotalpopulationcoverageof 92,138inAfghanistan.

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