World Health Organization - Afghanistan
From Health Relief to Health Reconstruction
in Afghanistan
WHO brief, 5 December 2001
for Afghan Support Group Meeting, 5-7 December 2001, Berlin, Germany
World Health Organization
Organisation Mondiale de la Sante
World Health Organization - Afghanistan
From Health Relief to Health Reconstruction
in Afghanistan
World Health Organization brief, 5 December 2001
SUCCESS OF AFGHANISTAN RECONSTRUCTION WILL BE MEASURED IN LIVES SAVED AND IMPROVED
GENEROUS SUPPORT FOR HEALTH WILL FOSTER PEACE AND DEVELOPMENT
"Whether in the emergency or the post-conflict reconstruction phase, the most important thing is to save and improve lives in Afghanistan. This is our number one goal," declared Dr Gro Harlem Brundtland, Director-General of WHO.
“Significant financial and technical resources are required more than ever before," warned Dr Hussein A. Gezairy, WHO Regional Director for the Eastern Mediterranean. "I truly hope the international community will rise to this occasion to prevent a health catastrophe in a highly vulnerable population whose suffering continues to be immense,"he said.
Health Relief for the next three months
The priority is to address the major causes of death and illness. In the next three months, WHO technical and financial resources will be focused on preventing preventable deaths. In the midst of the triple crisis of the worst drought, the most intense military action and widespread displacement, immense efforts have been initiated to prevent deterioration of the health situation. WHO Afghanistan predicted, based on previous trends, that, in addition to casualties from conflict, respiratory infections, maternal complications, and diarrheal diseases, would be the killers this winter due to serious depletion of family resources, poor nutrition, exposure during displacement, diseases increased due to crowding, and inadequate health care and referral services. Saving lives would depend on having health workers in the field and sufficient medical supply in both peripheral and referral centers as well as food, shelter and security.
WHO Afghanistan Implementation since September 2001:
WHO has almost 200 experienced national and international staff working in and around Afghanistan who are currently providing technical support to programs and responding to the emergency situation, especially Strategic Stockpiling, Increasing Health Services to Vulnerables, Control of Communicable Diseases, and Health Sector Coordination, which are detailed below.
Strategic Stockpiling: During October 2001, WHO shipped sufficient Emergency Health Kits into Afghanistan in October to serve 580,000 people for three months. While about 32% of the need has been met, more emergency medical supplies are still needed, especially in the North and South where there are large populations with inadequate health services as well as remote and chronically under-served mountainous areas of Bamyan, Badakhshan and Paktika. WHO has over 200 Emergency Health Kits in the pipeline which will be used during the winter to meet the health needs of one million people for a total of six months. Camps and settlements, housing more than one million IDPs, will also need to be carefully monitored and supported to be sure health services are adequately provided.
Increasing Health Services to Vulnerables: WHO has provided supplies to keep basic health services going, filling gaps in external support, including maternal care among internally displaced populations and other vulnerables, and has provided supplies to NGO health centers working in areas likely to soon become snow-bound. In three pilot districts in 8 regions, WHO has continued technical support to health and development committees in poverty stricken communities. In Faizabad and Kunduz, in IDP camps and host communities, WHO sponsored water and sanitation projects have provided safe water supply, latrines and bathhouses.
To prevent excess mortality in Afghanistan this winter, WHO has initiated mobilization of a health workforce in under-served districts. Those health workers that have no other external support will be provided with three months supply of drugs for 10,000 population and a three months’ contract to mobilize the outreach teams, distribute drugs and monitor the outcome. This is a stop-gap measure to cover the winter emergency until the health sector is rehabilitated.
Health Sector Coordination: WHO has facilitated weekly coordination meetings with all health sector agencies and provided a library of over 100 emergency manuals to the Afghan NGO Coordination Center in Peshawar. WHO in collaboration with ICRC facilitated a training course on medical emergencies in Kabul and has similar courses scheduled in Herat and Kabul. WHO disseminated new Guidelines for TB treatment during the Crisis and reprinted translated copies of Guidelines for Case Management of ARI, Diarrhea, and Malaria for distribution to health workers in IDP camps. The Manual for Basic Health Kit was translated into Dari and will be distributed along with the 231 Kits in the pipeline. WHO officers are also providing technical support for ongoing planning and monitoring in the health sector. The WHO rapid assessment of health facilities in Kabul, completed this week, is part of the process of needs assessment already initiated to enable evidence-based reconstruction planning.
Control of communicable diseases and surveillance: Two rounds of the polio eradication campaign were conducted in all regions of Afghanistan reaching over 5 million children under age five with each round. The commitment of WHO Afghan staff and volunteers in carrying on the house-to-house campaigns in spite of general insecurity is lauded.
Great efforts have been maintained to overcome the constraints and continue disease surveillance through WHO sub-offices. Supply hubs in Peshawar, Quetta, Mashhad, Turkmenabad, and Dushanbe have become coordination centers for flow of information and support to national staff in Afghanistan. Specimens for 16 cases of acute flaccid paralysis were successfully transported to the Islamabad laboratory, and an outbreak of falciparum malaria and cases of diphtheria were reported and responded in collaboration with NGOs. Focused effort needs to be made with collaboration of all health sector agencies to pool the available data and streamline the flow to provide the necessary feedback on the impact of interventions during the Crisis.
Remaining priority needs to reduce avoidable deaths this winter are:
- Providing essential drugs and supplies, including maternal and child health and micronutrient supplies, for basic health centers and outreach services in under-served areas and for referral centers near IDP camps.
- Mobilization and coordination of an additional workforce to meet the needs of IDPs and under-served areas. See attached map.
- Inputs for a responsive Health Information System
- Assessment and coordination of Reproductive Health interventions.
- Crash training courses for the winter emergency
- Replacing strategic stockpiles of drugs and supplies and strengthening surveillance for control of communicable diseases.
- Ensuring safe water, sanitation and environmental safety in areas of IDP settlements and host communities
Recruitment of national female coordinators and trainers is especially urgent.
The extent to which funds, supplies and workforce needs can be met may very well be the limiting factors in the extent to which the health sector partners are able to mitigate the combined impact of drought, displacement and conflict in Afghanistan this winter.
Preparation for Health Reconstruction
WHO experience in Kosovo and East Timor indicates that planning for the reconstruction of health sector, as well as for the other sectors, should start now, i.e. in the relief phase. Health sector rehabilitation must be initiated as quickly as possible, since equitable coverage and access to care will be major factors of support to local administration, social stabilisation and peace.
“Aside from relieving suffering, rebuilding the health sector is absolutely crucial for the future stability and socio-economic development of Afghanistan,” Dr Brundtland pointed out. “Investing in health, among other social services, is investing in peace and prosperity.”
WHO humanitarian emergency experts working on the Afghanistan crisis have indicated that health sector reconstruction must tackle the following five areas to save and improve lives:
1. Reproductive Health: Every day 45 women die of pregnancy related causes resulting in more than 16,000 deaths each year. Emergency obstetric care needs to be made available. Female doctors, nurses and midwives are sorely needed and existing health workers need further training to assure Safe Motherhood. Accessibility, availability and quality of comprehensive maternal and neonatal health care services need to be improved through training of existing health care providers in essential obstetric care and neonatal care, improved essential midwifery services and improved referral services that can manage emergency complications as well as through maximization of antenatal care coverage and tetanus toxoid immunization.
2. Child Health: One-fourth of Afghan children do not live to celebrate their fifth birthday. Acute malnutrition in children is estimated at 10% and chronic malnutrition is about 50%, making children all the more vulnerable to disease and death. Routine immunization needs to continue to be expanded and strengthened and country-wide catch-up immunization campaigns need to be undertaken. Other childhood killers such as acute respiratory infections and diarrheal disease need comprehensive prevention and control measures. Water-borne diseases account for more than 20% of childhood illness. Current coverage of 23% with safe water and 12% with sanitation systems needs priority in the reconstruction process. Other interventions such as community education in hygiene and nutrition and re-training of health workers on Integrated Management of Childhood Illnesses are also key to improving child health.
3. Communicable Disease Control: There are an estimated 72 000 new cases of tuberculosis each year in Afghanistan. Curing a patient requires DOTS[1] over months, so systems must be put in place to ensure drugs are available and cases are supervised and cared for during their recovery. Malaria, cholera, measles, typhoid, meningitis, and hemorrhagic fever occur as deadly outbreaks in different regions of Afghanistan. The epidemic of leishmaniasis, a disease carried by flies causing sores which disfigure the face, has spread to more than 80,000 people in Kabul. Communicable disease control needs a comprehensive environmental, community and case management approach through integrated primary health care services and multi-sectoral support.
Disease early warning and response systems need to be put in place and integrated all across Afghanistan. Health management information systems are in their infancy and need strengthening with information technology and training, streamlining and stable support.
4. Mental Health: It is estimated that 10% of a population living in a conflict zone suffers from mental health problems. Due to the ongoing war for the last 22 years, it is likely that most Afghans are suffering some level of stress disorder. Residual mental disease that one would see in any population has not been attended to for years in Afghanistan as it was mired in conflict, deepening poverty and enveloped by intolerance. Mental health services urgently need to be re-established.
5. Injuries: People with injuries due to landmines and unexploded ordnance need to be cared for, both in the immediate, and over the long term so that the disabled are re-integrated into society and able to lead productive lives.
Focusing on Primary Health Care and making it available to all the population, is the key to effective and efficient health services which can save and improve lives. Community based initiatives dealing with poverty reduction need to be strengthened and expanded at the same time as institution capacity building to rehabilitate Afghanistan.
Reconstruction must ensure that healthcare facilities are completely restored to ensure the provision of essential services, including referral services for emergency obstetric care. They need to be fully equipped with supplies, equipment, essential drugs and vaccines. Health posts need to be established in chronically underserved areas, and outreach teams need to be increased to reach the far corners of Afghanistan. There is a critical shortage of health care workers at every level. More doctors, of every specialty, nurses, midwives, lab and x-ray techs, pharmacists, dentists, and physiotherapists need to be trained.
Phases of Reconstruction:
During the 27-29 November Islamabad conference on Preparation for Reconstruction, three phases of reconstruction after the planning phase were identified.
- Immediate Interventions – Institutional and organizational support, repairing structures, delivering essential package of primary health care services, and re-establishing training institutions (Dec 2001 – Sept 2002)
- Transition Phase – Consolidation: Ensuring quality and equity (June 2002 – Dec 2003)
- Longer Term Activities - Expansion – Construction, return of Afghan health professionals and new graduates (Sept 2002-Dec 2007)
Reconstruction could begin as soon as a government, durable peace, security, funds, and an agreed long term plan were in place. A detailed needs assessment with costing and a timeframe should be developed working through the existing coordination mechanism, National Technical Coordination Committee which includes all stakeholders, chaired by MOPH. WHO staff and the partnerships they built for health through the various country programmes, will continue to provide technical support to the future Afghan government in health policy formulation and country, regional and sub-regional annual health planning.
The following are the immediate interventions envisioned by WHO Afghanistan:
1. Needs Assessment - Deployment of rapid health assessment tools to obtain priority needs and analysis for reconstruction
2. Coordination and collaboration with partners of planning for reconstruction; advocacy for standards, equity and stewardship.
3. Up scaling collection of health information: capacity building, replacement and expansion of disease surveillance sites; compilation, analysis, interpretation and information sharing with stakeholders
4. Up scaling referral centers for emergency obstetric care
5. Initiation of rehabilitation of medical education and health worker training institutions.
6. Up scaling inputs to capacity building in district health management
7. Reviving programs for prevention and control of communicable diseases.
- Tuberculosis
- Malaria
- Leishmaniasis
- Epidemic response
- Immunization
- Assuring safe water in five urban centers - Mehterlam, Ghazni, Jalalabad, Charikar, Shebergan - and villages in Kabul province and rehabilitation of chlorination systems in major cities
- Essential survival package in the Western Region to assure health care to under-served communities most vulnerable to displacement
- Community empowerment through Basic Development Needs program
Conclusion
In Afghanistan, investing in the health sector makes good sense for conflict prevention as well as for socio-economic development. Empirical evidence suggests that investing in health can reduce the risk of conflict as well as mitigating its impact. Through its work in complex emergencies, from Central America to Europe and South East Asia, WHO has seen health recovery support stabilization and peace. Initiatives have included humanitarian cease-fires, re-defining health districts along functional rather than ethnic lines, joint health training of former enemies and cross-community health initiatives at local level.
“Indications are that much needs to be done in this country whose long-lasting humanitarian crisis has led to a great accumulation of health needs. The international community must now seize what is an excellent opportunity to turn the health situation around in Afghanistan,” Dr. Brundtland emphasized, concurring with Dr. H. A. Gezairy who stated, “Significant financial and technical resources are required more than ever before," and called for strong investment in health, at this crucial moment, as a key to peace and socio-economic development.
WHO Afghanistan Plan for Health Relief to Health Reconstruction in Afghanistan (December 1, 2001 to September 1, 2002)Activities / Budget (USD)
Health Relief
1. Providing essential drugs and supplies, including MCH and micronutrient supplies, for 150 basic health centers and outreach services in under-served areas and for 25 referral centers for emergency obstetric care. / $2,500,000
2. Rapid assessments, mobilization and coordination of an additional workforce to meet the needs of IDPs and under-served areas. / $700,000
3. Inputs for a responsive Health Information System, Monitoring emergency health care in eight regions, Analysis and feedback. Publishing guidelines on emergency health management and control of communicable diseases. Coordination with partners. / $1,026,000
4. Assessment and coordination of Reproductive Health interventions. Support to referral centers for emergency obstetric care. Health education. / $330,000
5. Crash training of health workers at each level, doctors, nurses, lab techs and community health workers on emergency medicine and surveillance (about 2800 health workers, two trainers, male and female) and training materials / $145,000
6. Replacing strategic stockpiles of drugs and supplies for control of communicable diseases, Strengthening surveillance mechanisms and support to local staff in missions for emergency response, Laboratory and diagnostic support to detect and confirm outbreaks, Consultations for outbreak response. / $1,300,000
7. Ensuring safe water, sanitation and environmental safety in areas of IDP settlements / $1,000,000
Subtotal / $7,001,000
Preparation for Health Sector Reconstruction
1. Needs Assessment - Deployment of rapid health assessment tools to obtain priority needs and analysis for reconstruction / $250,000
2. Coordination and collaboration with partners of planning for reconstruction; advocacy for standards, equity and stewardship. / $100,000
3. Up scaling collection of health information: capacity building, expansion of disease surveillance sites / $200,000
4. Up scaling referral centers for emergency obstetric care and training of health care providers in essential obstetric care / $900,000
5. Initiation of rehabilitation of medical education and health worker training institutions in six regions. / $3,000,000
6. Up scaling inputs to capacity building in district health management and institutions / $250,000
7. Reviving programs for prevention and control of communicable diseases.
Tuberculosis / $1,500,000
Malaria / $300,000
Leishmaniasis / $250,000
Epidemic response / $300,000
Immunization / $1,200,000
8. Assuring safe water in five urban centers - Mehterlam, Ghazni, Jalalabad, Charikar (Parwan), Shebergan; villages in Kabul province; and rehabilitation of chlorination systems in major cities / $2,488,000
9. Essential survival package in the Western Region / $6,600,000
10. Community empowerment through Basic Development Needs program / $500,000
Subtotal / $17,838,000
Program Support Cost (0.06) / $1,490,340
TOTAL / $26,329,340
[1] Directly Observed Treatment Short-Course.