Moreover, even among those who survive infancy, health expectations are low. More than half of Afghanistan's children are stunted, and many suffer from iodine deficiency, which lowers the average IQ by 10-15 points leading to poor school performance. The consequences of such poor health standards for the development of Afghanistan should not be underestimated.
Afghanistan inherited a health system from the eighties, which was geared to curative care and not for public health problems of this magnitude. This system has suffered not just from the fighting, but also from the succession of different regimes and consequently a high turnover of senior staff as well as constant changes in policy-making. Lack of public financing has led to an almost complete reliance on external assistance with over 70 per cent of health services provided by UN and non-governmental organizations (NGOs).
Progress so far...
A key element has been the move towards institutional strengthening which has included the provision of institutional and technical support to the Ministry of Public Health (MoPH) in order to strengthen its capacity in the areas of policy development, strategic planning and implementation.
A programme secretariat headed by the MoPH with support from the World Health Organization (WHO); United Nations Children's Fund (UNICEF); United States Agency for International Development (USAID); the European Union (EU) and; Medical Services for Health (MSH) - an NGO, has committed itself to a basic package of services, which are accessible, equitable and sustainable. These will be supplemented by various projects of the Transitional Assistance Programme for Afghanistan. Action has already been taken in four key areas:
Institutional Strengthening: The Ministry has formulated a national public health care policy with technical working groups for specific sectors, including HIV/AIDS, nutrition, safe motherhood and immunization. Fifty health centres have been established round the country to deal with the distribution of basic and emergency health kits, while 500 traditional birth attendance kits and 400 community health workers kits are being distributed in selected rural areas after training on their use. A nationwide survey on health facilities was completed and results were available at .the end of 2002. In addition, a national workshop on communicable disease control was conducted for 80 MoPH staff members.
Maternal and Child Health: A Maternal Mortality Survey has estimated that about 87 per cent of maternal deaths can be prevented, although rates varied greatly according to region and rural and urban settings. Kabul for example had a maternal mortality rate (MMR) of 400 per 100,000 while Badakshan with 6,500 per 100,000 was the highest ever reported globally. The largest maternity hospital in Kabul, Malalai, has been refurbished with new water and sanitation facilities, and supplied with equipment and drugs. A "Centre of Excellence" for emergency obstaetric care has also been established in this hospital and a core team already trained in emergency obstaetrics care. In addition, 12 regional hospitals and 40 other facilities round the country have been supplied with equipment and supplies. The MoPH has received support for the coordination of reproductive health related activities, through mechanisms such as the National Reproductive Health Coordination Meetings, and participation in senior level forums such as the Health Coordination Taskforce, which is supported by the United Nations Population Fund. Programmes of international study tours have begun for MoPH staff at several levels while the Government has drafted a national policy for reproductive health. Through partnerships with NGOs, emergency obstetric care services are being supported in 20 districts while the Afghan Society of Obstetricians and Gynaecologists has been founded. The midwifery curriculum is being developed and different training programmes are ongoing, targeting female healthcare workers. Information on health and reproduction is being broadcast throughout the country in the BBC's "New Home, New Life" radio drama, in Dari and Pashto.
Nutrition: Surveys focussing on needs are being conducted in a number of areas, particularly those affected by drought. But already the Ministry of Public Health, in conjunction with UNICEF, WFP and several NGOs, is supporting supplementary feeding programmes for pregnant mothers and more than 320,000 children under 5 years of age, through 174 feeding centres. Over 3000 metric tonnes of nutritional food has already been distributed. A national iodized salt programme to treat iron-deficiency anaemia has begun as well while a nutrition technical unit has been established in the MoPH in conjunction with Tufts University. Sub-national standards for nutritional surveys and surveillance systems as well as policies and protocols on infant feeding; management of severe malnutrition; treatment of scurvy and nutrition; food security surveys and surveillance have been developed by the Unit.
Immunization: Four national and several national Polio Immunization Days in 2002 have reached six million children during each round. Forty polio immunization posts were established on border crossings from Pakistan to ensure that returning children were also covered. Vitamin A supplement was distributed to five million children. A measles campaign reached more than nine million children (almost 90 per cent of the target) while 10,000 vaccinators and volunteers were trained for the operation. This campaign alone should avert 35,000 child deaths per year. Critical equipment, including 975 refrigerators, 120 freezers, 600 cold boxes, 75 generators and 4,800 vaccine carriers have been procured and partially distributed in order to revitalize the cold chain infrastructure of the Eradication of Polio Initiative (EPI).
Priorities for 2003...
The MoPH's strategy will both target leading causes of morbidity, particularly among women and children as well as improve access to basic health services including immunizations, essential obstetric care, integrated management of childhood illnesses and health and nutrition education projects. UN agencies and NGOs are actively assisting the Ministry with these goals, providing financial, technical, logistical, and managerial assistance.
Afghanistan is well on the path towards eradication of polio and the national immunization campaign (to eradicate Polio) will continue, with five national immunization days and other supplementary mop-up campaigns planned for 2003. Measles "catch-up" campaigns will also be conducted for children between 6 months and 5 years old. As well as technical assistance provided in the country critical institutional links are being provided to global networks and scientific institutions. The polio and measles campaigns as well as a tetanus campaign (particularly important for expectant mothers) slated to begin in 2003 are all initiatives that will involve experts from several countries and agencies and allow Afghanistan to benefit from lessons learned elsewhere. Also as UN staff members decrease in the next two years, such partnerships will allow the MoPH to benefit from continued technical expertise and lead to direct funding, particularly for training programmes.
A major effort will be to continue to reduce maternal mortality. A wide range of NGOs and international institutions will support the MoPH in this. "Centres of Excellence", similar to the one in Kabul's Malalai hospital, will be established in maternity hospitals in Kandahar, Herat and Jalalabad. Clinical staff will be trained, delivery rooms renovated and essential drugs and equipment provided. Also it is expected that the core team trained at the "Centre of Excellence" in the Malalai Hospital will be ready to train health providers from across the country in June 2003. Other initiatives such as a "Making Pregnancy Safer" strategy and the "Mother-Baby Package" will equip seven hospitals and 28 Mother Child Health Centres in targeted provinces to provide comprehensive and basic emergency obstaetric care services. In 2003, the WHO also plans to support a large-scale revitalization of the blood banks around Afghanistan. Support will continue for the MoPH Nutrition Surveillance Unit, to monitor needs round the country, particularly in the drought-affected regions of the southwest. Extensive assistance will also be provided towards institutional strengthening of the MoPH, ranging from policy technical assistance in the development of national plans, standards and policies, to study tours, training programmes and material support.
There are other factors that will define health provision in Afghanistan. They include reform of health administration; more decentralisation; development of financial planning; redressing the bias of healthcare provisions that currently favour Kabul and other major urban centres; further development of health policies; and addressing the distortion in the composition of the healthcare work force.
In 2003 the MoPH will enter into partnership with selected NGOs to ensure expansion of the basic package of health services as widely as possible across the country, particularly in remote and underserved areas. UN agencies and donors will continue to provide technical and material assistance that will increase the capacity of the MoPH to manage the health and nutrition sector.
All UN programmes lend support to the Afghan transition process and to the lead role played by the Afghan Administration. In addition to UNAMA, there are some 16 UN agencies in Afghanistan working with their Afghan Government counterparts and with national and international NGO partners. The Special Representative of the Secretary-General for Afghanistan heads UNAMA and has overall responsibility for UN activities in the country.