Health and nutrition
Through a continuum of care approach with a strong focus on equity, UNICEF Afghanistan’s Health and Nutrition programme contributes to the achievement of MDGs 1, 4, 5 & 6 in Afghanistan. The programme is also aligned with the UNDAF outcomes and the Afghanistan National Development Strategy (ANDS) by increasing access to and utilisation of high quality, evidence-based maternal, newborn and child health and nutrition services at facility and community levels.
Afghanistan has the second highest rate of under-five mortality in the world, with thousands of children dying every year. The under-five mortality rate (U5MR) is 101 per 1000 live births, the infant mortality rate (IMR) is 73 per 1000 live births and the neonatal mortality rate (NMR) is 36 per 1000 live births. Across Afghanistan, every two hours a woman dies due to pregnancy related causes. Under the current conditions, approximately one in 50 women in Afghanistan has a lifetime risk of dying due to pregnancy related causes. UNICEF Afghanistan’s Health and Nutrition programme focuses on contributing to the reduction of maternal newborn and child mortality and morbidity in Afghanistan.
Routine Immunisation -
The Convention on the Rights of the Child states that all children must have equal access to adequate health care. UNICEF considers protection from vaccine preventable diseases to be a child’s basic right, like food and shelter. As part of essential interventions to promote child survival, Immunisation is made a priority on the map of global issues; UNICEF has participated in the development of the Global Vaccine Action Plan (GVAP), an ambitious roadmap to deliver universal access to immunisation, which requires continued and steadfast support from donors, governments and partners.
In addition to supporting Afghanistan’s programme to eradicate polio, UNICEF works to ensure children and infants receive the full range of routine vaccinations, through procurement of vaccines, support the establishment of cold rooms and vaccine management, training of vaccinators and supervisors and communication for strengthening routine immunisation.
UNICEF also supports Vaccination Weeks that promote awareness on the unique needs of children, and offer opportunities for mothers and children to be vaccinated. UNICEF supports measles and tetanus immunisation drives in selected provinces and in response to outbreaks.
UNICEF is also technically and financially supporting the undertaking of National EPI Coverage Survey in the country.
55 per cent of Afghan children under the age of 5 cannot develop physically or mentally, as they should, because of chronic nutritional deficiency. Children in the poorest communities are more than twice as likely to be stunted as children from the richest communities. Stunted children are also more likely to contract diseases and lack access to basic health care, and to not attend school. Girls who are stunted are more likely to give birth to babies who have a higher chance of becoming stunted. UNICEF is supporting nutrition activities in 30 provinces so that 30 per cent of under five children and pregnant and lactating women have access to and utilise quality community and facility based interventions for the prevention and management of malnutrition (Severe Acute Malnutrition (SAM), stunting and micronutrient deficiencies. UNICEF manages Community Management of Acute Malnutrition (CMAM) programmes through NGOs in these 30 provinces, including the procurement of supplies for 55 Therapeutic Feeding Units (TFUs).
UNICEF, in collaboration with WHO, is in the process of establishing a National Nutrition Sentinel Surveillance System. UNICEF is also technically and financially supporting the National Nutrition Survey and developing a national nutrition communication strategy with a focus on the first 1000 days as the “window of opportunity.”
UNICEF is currently the lead agency for the Nutrition Cluster in Afghanistan, a consortium of government and NGO partners that coordinate emergency preparedness and response. As the Nutrition Cluster lead, UNICEF is working to identify and address cluster capacity and resource gaps in order to make sure the nutrition situation is monitored and the needs of children and pregnant and lactating women are addressed both in day-to-day and emergency situations.
Maternal Newborn and Child Health
UNICEF contributes towards achieving the goal that 60 per cent of pregnant women, newborns and under five children have access to a quality, community-based minimum package of health and nutrition services, including mothers with complicated pregnancies having access to quality Emergency Obstetric and Neonatal Care (EmONC) services. The services are delivered to complement ongoing BPHS/EPHS activities in underserved and unserved areas. At the community level CHWs and FHAGs are trained on pictorial models of community counseling flip charts, while underserved areas are covered by mobile health units and outreach teams, health facilities are strengthened for delivery of quality maternal and child health services, six maternity waiting homes are also supported throughout the country. UNICEF has also supported the development of a national policy and strategy on reproductive health and HIV/AIDS and the development of guidelines on IMCI,
Prevention of Parent-to-Child Transmission (PPTCT) of HIV
and maternal death notification. UNICEF also supports five regional hospitals for the provision of PPTCT services.
Health - Current situation and key issues:
One of the key underlying factors contributing to maternal mortality in Afghanistan is the near-total absence of accessible hospital services for complicated births. UNICEF is supporting an innovative models to improve mother and child health outcomes in five provinces of Bamyan, Badghis, Kandahar, Helmand and Uruzgan. The project will provide 500 locally made transports (Zarang) and will provide incentives to CHWs for improving referrals of pregnant mothers for antenatal care and facility delivery and under 5 children for Penta 3 vaccine and management of severely acute malnourished children. The programme is also piloting community transport funds and the use of mobile phones for social mobilisation and referrals.
The under-five mortality rate in Afghanistan has been reduced from 192 per 1,000 live births in 1990 to 136 in 2000 and 101 in 2011 – a 47% fall.
The infant mortality rate was also significantly reduced, from 129 per 1,000 live births in 1990 to 73 in 2011. Despite these encouraging trends, it is far from guaranteed that the MDG4 target of reducing under-five mortality to 64 per 1,000 live births by 2015 will be attained. Neonatal deaths (35%), Acute respiratory infection (23.4%), other serious infections (19.7%), diarrhea (6.2%), and measles (2.1%) are the major cause of under five deaths. Malnutrition (including acute and chronic cases) is a cross-cutting cause in 45% of under-five deaths. The situation is perpetuated by other factors related to supply side barriers such as distance and access to health facilities, non-availability of skilled service providers, insecure areas and demand side barriers including poverty, high out of pocket expenses, difficult terrains, harsh weather and various social norms including low status of women, preventing her to take child to health facility without a male family member.
The maternal mortality ratio (MMR) in Afghanistan has been reduced from 1300 per 100,000 live births in 1990 to 460 per 100,000 live births in 2010, an encouraging 65% fall. But the country still needs to reduce the ratio by a further 35% by 2015 to meet the MDG5 target of 325 deaths per 100,000 live births.
Despite the decline in maternal mortality, pregnancy-related deaths remain a leading cause of death (41%) for women in their childbearing years. Under current conditions, a woman has a 1-in-32 chance of dying from pregnancy-related causes during her lifetime.
Hemorrhage is by far the leading cause of maternal deaths in Afghanistan (56%), followed by eclampsia (20%) and prolonged or obstructed labor (11%). The major underlying causes of maternal deaths include poor antenatal care (48%), low skilled attendance at birth (39%), Early child bearing (26%), high fertility rate (5.1%), low contraceptive prevalence rate (21%) and maternal anaemia (16%).
During last five years the Ministry of Public Health has made major strides in decreasing maternal and under-five mortality in Afghanistan, but there are widespread inequities in all indicators such as full immunization rate is 30 per cent nationally but in southern region it is only 2 per cent; similarly nationally 39 per cent of women deliver by skilled birth attendant, it is 76 per cent for richest wealth quintile while only 16 per cent for the poorest quintile. The gains in maternal and child health are greatly contributed to by the political commitment of the Government resulting in a strong focus on maternal and child health in all key policy and strategic documents including Afghan National Development Strategic Plan, health sector policy and strategic plan and National Priority Programmes.
These directions increased the coverage of health service delivery resulting in increased MNCH intervention. However due to contracted out model of health service delivery through Basic Package of Health Services (BPHS) to NGOs and in absence of strong accountability system, the service delivery is mainly curative and urban focused (accessible to 57% population) and out of pocket expenses are high (75%). Presence of Anti-Government Elements (AGE), insecurity and conflict affected areas remain a challenge in service provision. In addition, weak governance particularly in the areas of policy analysis, strategic planning, health human resource planning shortage of qualified nurses, midwives and other female health workers in the country, Rural – urban disparities in the distribution of human resources are a great challenge in improving the coverage of maternal and child health services.
Nutrition - Current situation and key issues: Nutrition is both an immediate and an underlying cause of maternal and under 5 mortalities in Afghanistan. Under-nutrition contributes to 45% of under-5 deaths globally in the form of foetal growth restriction, sub-optimum breastfeeding, stunting, wasting and deficiencies of vitamin A and zinc.
Afghanistan has the world’s highest rate of stunting in children under
five – 60.5% (this is a 2004 figure; the latest National Nutrition Survey 2013
is in preparation). Such high stunting rates are considered “a silent
emergency”. Disaggregation by age from 2004 survey reported stunting in 70% of
children between 2 to 3 years of age.
Nutritional status of children is highly correlated with the nutritional status of mothers. There is a vicious cycle of malnourished mothers having small babies who grow up to become stunted mothers. In societies where women lack empowerment women and children suffer from poor nutrition status, and this has a direct impact on national GDP and the IQ of the next generation.
Despite improvements in health outcome indicators over the past decade, the health system still faces a number of challenges.Nutrition services are limited at all levels in Afghanistan and only starting to be addressed in the recent years. There is no dedicated in-service training or trained health-care providers who can offer counseling on maternal and child nutrition or assess under-nutrition. As a result, rates of stunting, severe acute malnutrition and micronutrient deficiencies are underestimated and receive much less focus than they should. Detailed causality analysis indicates clearly that not only do investments in the health and nutrition sector need to be sustained and expanded, but also that the best and most cost-effective results will come from a comprehensive multi-sectoral approach involving all the tools available in the pursuit of human development.