2000 AFG: Safe Motherhood Initiative in Afghanistan
Author: Mawji, S.
Afghanistan, where the maternal mortality ratio is estimated to be the second highest in the world at 1,700/100,000 live births, warrants the implementation of effective interventions to reduce maternal mortality. UNICEF, in collaboration with other stakeholders, developed a strategic framework for Safe Motherhood in late 1997. This strategy was to be implemented initially in 'focal' provinces and it was envisioned that the experiences gained would later be used to replicate this programme in other parts of the country.
Purpose / Objective
In an effort to assess the progress that has been made over the past 3 years, to consider the lessons learned and to develop effective ways to move forward, UNICEF recruited an external consultant to review the safe motherhood programmes in Afghanistan. This report is an analysis of the current situation of the safe motherhood programme in the 4 focal provinces that UNICEF has targeted - Logar, Laghman, Farah and Balkh - and offers recommendations for operationalizing the safe motherhood programme.
Objectives of assessment:
- Carry out an assessment of UNICEF-supported Safe Motherhood projects
- Draft plan of action for the reduction of MMR, covering the period of July 2000-Dec 2002
- Contribute to the implementation of the plan of action for Logar province
- Recommend changes in the managerial structure, staffing and other inputs for better programme implementation
Information was gathered and collated through:
- Review of available reports and documents
- Interviews with key informants: representatives of UN agencies, international and local NGOs as well as MoPH officials (in Afghanistan, Peshawar and Islamabad)
- Completing a questionnaire - facility assessment form - via observation and interviewing
- Visits to most districts and health facilities in each focal province
- Discussions with health care professionals, especially female staff as well as health care users
Key Findings and Conclusions
On the whole, the Safe Motherhood programme (SMI) in Afghanistan is still very much in its infancy. Although 5 provinces had initially been identified as focal provinces in 1997, in fact 4 provinces are now the SMI focal provinces for UNICEF. The SMI programme was to be incorporated in the overall plan for strengthening primary health care services (PHC), but in actual fact, this has not been realized. The achievements related to the implementation of the SMI programme have varied between each province.
Though almost 3 years have passed since the consensus-building workshop on the strategy for Safe Motherhood in Afghanistan was held and there were some very clear recommendations for follow-up action, it appears that most of these actions have not been implemented. The tendency for UNICEF up till now in most of the focal provinces, had been to supply equipment, drugs and other materials to health facilities/hospitals as well as to work on aspects related to renovation and rehabilitation. However, in most of these areas, there is no monitoring or supervision systems set in place nor is the staff actually trained or oriented to provide emergency obstetric services. Various other essential facets of implementing the safe motherhood programme have yet to be actualised. The development of national training materials for health staff on provision of emergency obstetric care is one such example.
In reality, little advancement and progress has been made in Afghanistan over the past few years in improving conditions that can facilitate improvement for maternal health. It is important to note that in 1998, most of the international staff had been evacuated from Afghanistan. National staff continued to manage the programme on a skeletal basis. Many other reasons can be cited for this lack of progress, but two of the crucial ones that underpin these are:
- The ongoing complex political situation in Afghanistan that has resulted in the instability of implementing most programmes and the continued fundamental patriarchal society that is exemplified in the lack of basic human rights for women. The lack of political will on the side of the authorities, the low level of decision making of women, the ongoing ban of formal education for girls, the restriction of movement for women, the lack of qualified female staff available to work in rural areas and the difficulties which lie in providing training for female health professionals all have contributed to the slow progress of the SMI program in this country.
- The under-performance and shortfall on the side of UNICEF Afghanistan to view the Safe Motherhood Initiative as a programme, to develop the appropriate materials required for this initiative and to give it the time and effort that it rightly warrants. Part of this reason may be due to the strong focus within the Survival section/ Health section to concentrate on issues related to EPI (expanded program of immunization). Another explanation for this lack of movement in the SMI program may be related to the lack of adequate human resources within the women's health section. Currently, one Afghan female staff member in ACO is directly responsible for this program. This staff member's movements are very much restricted within Afghanistan as she must travel with a mehram and cannot meet with senior authorities or attend formal meetings within Afghanistan. There are also a lot of other responsibilities that she must undertake within ACO that take away from her focus on women's health and the SMI programme.
On an optimistic note, some progress has been made towards creating awareness amongst the authorities, the NGOs, health professionals and the community to a certain level as to what the Safe Motherhood programme entails. There have been national consultants recruited to initiate the Safe Motherhood programme in 3 of the 4 focal provinces and these have had varying degrees of success.
The general findings of this review should be seen in the complex situation that faces Afghanistan. In a country that has been at war for over 20 years, has a large geographical distribution and many inaccessible areas due to the physical terrain and climate, has no recognized government and the authorities who are in control are very weak in terms of their knowledge and managerial experience, where there has been a huge brain drain - professionals leaving the country - putting into practice any programme has been a real challenge.
The recommendations relate to implementing safe motherhood in a broad manner whereby intersectoral linkages among health, education, nutrition, gender and communication need to be addressed. Considering the context of Afghanistan and the current status of girls and women in this country, an assertive, yet tactful and diplomatic, approach must be taken in addressing these sectors.
In summary, UNICEF must take more of an active and leading role in the execution of the safe motherhood programme. It needs to coordinate and share information more openly with the other stakeholders, such as other UN agencies, MoPH and NGOs. UNICEF needs to spearhead this initiative, be more forthcoming and committed to this programme and develop the materials/tools that will enable the actualization of the safe motherhood programme in Afghanistan.
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