Achieving Maternal and Child Health Gains in Afghanistan: A Case Study

Achieving Maternal and Child Health Gains in Afghanistan: A Case Study

Background Afghanistan lies in one of the most strategic and volatile geo-political regions of the world Afghanistan has had a long standing history of conflict and in recent years, active regional and sub-regional spanning well over 3 decades Conflict and war has consumed many lives, displaced millions of others, devastated health and social infrastructure, and adversely impacted civilian health outcomes (WHO, 2001) The post-conflict 2001 period has witnessed relatively stable governance, substantial infrastructure rebuilding, progress in immunization and health policy/programmes

Afghan Government Response The Ministry of Public Health (MoPH) of Afghanistan has been very active since 2002 in addressing key gaps in MNCH Establishment of BPHS (2003), EPHS (2006) Routine immunization reactivated (child and maternal) (2002) Community based health care strengthened (2005) Community and facility based midwive training (2002) many other initiatives have been deployed to support health improvement in Afghanistan:

Rationale However to date, little systematic information is available on progress in child and maternal health and survival over the past decade A comprehensive, systematic analysis of health gains, progress and challenges in Afghanistan was undertaken by an independent group of academic experts in collaboration with the Institute of Public Health, Afghanistan

Methods An in-depth review was conducted of all available electronic published and unpublished reports pertaining to the situation analysis of RMNCH in Afghanistan since 2001, and relevant policies, program strategies and interventions, and official reports about progress towards MDGs Original data from all post-2001 nationally representative surveys were analyzed for national, regional, and provincial level estimates of various RMNCH indicators over time Infant, neonatal, and child mortality time trends were constructed from UN-IGME and IHME estimates Correlations, Student s t-tests, and linear mixed model statistical methods were employed to examine associations between variables SAS and STATA software were used for all statistical analyses

Data Sources S.# Survey List Year Published Report Dataset Representativeness 1 NNS National Nutrition survey 2013 In Process National & Provincial 2 NNS National Nutrition survey 2004 National 3 AHS Afghanistan Health Survey 2012 National 4 AHS Afghanistan Health Survey 2006 National 5 MICS Multiple Indicator Cluster Survey 2010-11 Regional 6 MICS Multiple Indicator Cluster Survey 2003 Regional 7 AMS Afghanistan Mortality Survey 2010 Regional 8 NRVA 9 NRVA National Risk and Vulnerability Assessment Survey National Risk and Vulnerability Assessment Survey 2007-08 Provincial 2005 Provincial

Key Results: Child Mortality 160 Under 5 Infant Neonatal Mortality Rate per 1000 live births 140 120 100 80 60 40 20 0 124.4 87.5 41.3 98.5 71.0 36.0 Neonatal, infant, and under 5 mortality trends from 2000 to 2012. Data sources: United Nations Inter-agency Group for Child Mortality Estimation

Key Results: Immunization Coverage 2003-2004 (%) 2005-2006 (%) 2007-2008 (%) 2009-2010 (%) 2011-2012 (%) Child (0-59 months) and maternal immunization trends from 2003 to 2013. Data sources: Multiple Indicator Cluster Survey 2003/04, 2010/11. National Risk and Vulnerability Assessment, 2005/06, 2007/08, 2010/11. Afghanistan Mortality Survey, 2010. Afghanistan Household Survey, 2012. Expanded Program on Immunization Census, 2013. Where more than two data points were available for the same period, the most recent was shown *possible artifact due to limitations in survey estimation method 2013 (%) Average annual rate of change (%) Immunization BCG 38.6 70.2 74.0 64.2 80.0 79.8 7.5% Polio3 50.8 69.7 71.0 48.0 49.6 61.2 1.9% DPT3 (pre-pentavalent) 30.1 34.6 41.2 40.2 46.7 NA 5.0% Pentavalent1 NA NA NA NA NA 75.6 NA Pentavalent2 NA NA NA NA NA 69.4 NA Pentavalent3 NA NA NA NA 46.1 62.3 35.1% Measles 30.9 62.6 56.2 55.5 58.4 60.9 7.0% Fully Immunized Child NA 27.1 37.0 18.0 29.5 48.0 7.4% Vitamin A Supplement NA 76.5 66.7 50.6 37.1 NA -8.6% Maternal TT 39.1 23.6 28.9 41.0 15.1* 81.0 7.6%

Key Results: Child Undernutrition 100 Stunting Wasting Underweight 90 80 Prevalence (%) 70 60 50 40 30 60.5 33.9 54.1 43.1 25.1 25.5 20 10 8.8 13.2 9.0 0 2004 2011 2013 Trends in undernutrition outcomes among children 6-59 months from 2004-2013. Data sources: National Nutrition Survey, 2004, 2013. Multiple Indicator Cluster Survey 2010/11.

Key Results: Human Resources Scale Up 7000 MD Specialist MD Generalist Nurse Midwife 6000 5000 Frequency 4000 3000 2000 1000 0 2005 2006 2007 2008 2009 2010 2011 2012 2013 Trends in facility based human resources deployed from 2005 to 2013. Data source: Ministry of Public Health, Government of Afghanistan.

Key Results: Skilled Birth Attendance Prevalence (%) 50.0 45.0 40.0 35.0 30.0 25.0 20.0 15.0 10.0 5.0 0.0 46.1 38.6 24.0 19.0 14.3 2003-2004 2005-2006 2007-2008 2009-2010 2011-2012 Time Period Trend in skilled birth attendance from 2003 to 2012. Data sources: Multiple Indicator Cluster Survey 2003/04, 2010/11. National Risk and Vulnerability Assessment, 2005/06, 2007/08, 2010/11. Afghanistan Mortality Survey, 2010. Afghanistan Household Survey, 2012 Where more than two data points were available for the same period, the most recent was shown

Key Results: Facility Based Births Prevalence (%) 45.0 40.0 35.0 30.0 25.0 20.0 15.0 10.0 5.0 0.0 38.6 38.8 20.9 12.8 14.6 2003-2004 2005-2006 2007-2008 2009-2010 2011-2012 Time Period Trend in facility based births from 2003 to 2012. Data sources: Multiple Indicator Cluster Survey 2003/04, 2010/11. National Risk and Vulnerability Assessment, 2005/06, 2007/08, 2010/11. Afghanistan Mortality Survey, 2010. Afghanistan Household Survey, 2012 Where more than two data points were available for the same period, the most recent was shown

Challenges Despite progress in reducing stunting, undernutrition rates are high (stunting: 43.1%; underweight: 25.5%), and could be a major limitation to progress Child vaccination rates in Afghanistan are still less than optimal and lag behind those of other Asian countries Neonatal mortality rates have not reduced significantly over the past decade and account for at least 36.0% of all under 5 deaths in Afghanistan (UN-IGME, 2013)

Conclusions Notwithstanding huge challenges and limited resources, Afghanistan has made remarkable progress in addressing some of the key bottlenecks in human resources for child birth and increasing delivery options for immunizations Future strategies should focus on scaling up coverage to reduce inequities and differentials, especially among rural poor and conflict zones Further progress in reducing child mortality would need a specific focus on improving access to skilled care at birth, reducing neonatal mortality and improving the quality of care in referral facilities