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Base de données d'évaluation

Evaluation report

2002 AFG: Assessment of Services and Human Resource Needs for the Development of the Safe Motherhood Initiative in Afghanistan

Author: Dalil, S.; Fritzler, M.; Ionete, D.; McIntosh, N.; O'Heir, J.; Stephenson, P.

Executive summary


Afghanistan's maternal health indicators are among the worst in the world. During 20 years of conflict, drought, political instability and isolation, the toll on the health of women and children has been staggering. The Afghanistan Ministry of Public Health (MOPH) is strongly committed to reducing maternal and neonatal mortality. From the Ministry's perspective, immediate action is needed, with a focus on extending the reach of life-saving care as close to the family as possible. UNICEF has, for several years, supported the implementation of the Safe Motherhood Initiative (SMI) in Afghanistan and many activities are currently ongoing in selected locations.

Under the new national and political conditions, the MOPH requested UNICEF to support the Ministry in developing and implementing national maternal health and safe motherhood policies and programs, as well as coordinating the interventions of donors in this subsector. To do this, UNICEF works in close partnership with WHO and UNFPA in the overall sector of reproductive health. In order to carry out its responsibilities, UNICEF organized an assessment of services and human resource needs for strengthening the SMI.

Purpose / Objective

UNICEF organized an external team of consultants to conduct an assessment of services and human resource needs for developing the Safe Motherhood Initiative (SMI) in Afghanistan. Specifically, the team was asked to:

- Assess the accessibility, quality and utilization of emergency obstetric care services and identify immediate and medium-term needs to be addressed in order to improve coverage and quality of care

- Assess the current status of staffing for Emergency Obstetric Care (EmOC), identify immediate and medium-term needs, and suggest short-, medium- and long-term strategies for human resource development, including proposals for curricula reform, with special attention to midwifery development

- Identify specific and critical points for the implementation of the Averting Maternal Death and Disability (AMDD) project in Afghanistan, particularly focusing on blood transfusion and transport services

- Assess the EmOC training program being implemented currently and check how it fits in the proposed strategy and in the forecasted implementation of the AMDD project

- Identify key implementation partners such as national non-governmental organizations (NGOs) and donors to support service delivery and training

- Liaise with the Centers for Disease Control and Prevention (CDC)/UNICEF maternal mortality study team to ensure that both assessments contribute to our overall understanding of factors contributing to maternal mortality and morbidity


The team visited five regions of the country and Kabul. In each region, we visited regional health directors and MCH directors, NGO partners involved in providing safe motherhood services, facilities offering basic and comprehensive EmOC services, and intermediate medical education schools (IMES). Additionally, when time permitted, we attempted to identify and meet with service providers for internally displaced persons (IDP) and women's organizations involved in community mobilization activities and advocacy. Security considerations and complex logistics associated with current air and road travel between points in Afghanistan limited travel to some extent.

Detailed facility assessment forms developed by WHO and adapted for the purpose of this needs assessment guided the data collection and discussions. Beyond this formal approach, the team sought to learn from the experiences and perspectives of Government officials, regional coordination teams, NGOs, service providers and educators. Likewise, we reviewed a number of documents containing useful data to help in our understanding of the situation of women and newborns.

Key Findings and Conclusions

During the course of the assessment, the team identified a wide range of opportunities already existing in Afghanistan, upon which actions to reduce maternal and neonatal mortality could be built. NGOs have continued to operate in past years under very difficult circumstances and have developed a wealth of experience. They have entrée to communities and have successfully developed partnerships with local government and traditional leaders. Moreover, they have leveraged resources from donors for the continuing operation of services. In some instances, NGOs have developed the local capacity for sound management of commodities and logistics systems. These and other best practices can be shared with other NGOs and with providers working in the public system to raise the quality and efficiency of health services.

For example, nutrition and therapeutic feeding services are available in many clinics. NGOs and donors have helped ensure supplies of drugs and consumable supplies. The Expanded Program on Immunization (EPI) services located in MCH clinics provide women with access to tetanus toxoid to prevent deaths from postpartum and neonatal tetanus. NGOs and other organizations have developed health information systems at the local level for tracking program activity and monitoring progress; these could provide a detailed and valuable resource to health care programs and providers. Newer indigenous NGOs or civil society organizations have come on the scene that could also contribute to the SMI. For example, women's groups have sprung up to address the recognized need for advocacy and improving access to health information and services at grassroots level.

Additionally, coordination mechanisms exist at regional and local level to promote information sharing and planning. Primary health services, including MCH services, have been de facto decentralized as a consequence of the prolonged strife in Afghanistan. Coordination mechanisms have evolved at regional and local level to promote information sharing and planning.

Because the regions are so different and findings from one area do not necessarily generalize to the others, we have presented findings and made recommendations for each region separately in the full report. These sections describe assessment findings for sites observed in each of the regions visited, highlighting local factors that could affect efforts to improve access to Safe Motherhood and EmOC services.

The areas visited also shared many similarities. Some of these were common shortcomings in resources, management, infrastructure, practices, knowledge, and skills. Many of these may be addressed by strengthening national standards of practice, e.g., infection prevention in hospitals and clinics. Others, such as restored and improved educational institutions and capital resources for infrastructure improvements, will take more time and a revitalized peacetime economy.

Best practices common to all regions visited:

Across all regions visited, effective partnerships have emerged between and among local and international NGOs and the MOPH. This helps to prepare the way for evolving relationships and partnerships in building on the SMI and delivering EmOC.

At the community level, services have been maintained, although sometimes at very minimal levels, despite years of little or no support. Physicians, nurses, midwives, and other community health workers, largely working through local and international NGOs, have striven, often against extreme odds, to bring health services to families.

The forced "decentralization" of recent years has led communities and partnering NGOs to make the most of their limited resources. As a consequence, many have developed local capacities for coordination and communication that, when coupled with the planned increased ability of the MOPH to support them, can enable services to be expanded in order to reach further and to more effectively serve the population.

Issues common to all regions visited that need improvement:

In nearly all cases, management and supervision systems within health services, especially regional, provincial and district hospitals, need updating and strengthening.

Managers of healthcare facilities need refresher training in sound management, administration and supervision policies and practices. In addition, they need consistent support and, in some cases, more personnel are needed.

Across all regions visited, the assessment found weak adherence in clinics and hospitals to recommended international infection prevention practices, including handling and disposal of sharp objects and bio-hazardous waste, and equipment operation, care and maintenance.


Now, in the changed political environment, the MOPH is increasingly able to take on a national perspective and tackle the task of developing national standards in healthcare and service delivery. With support from UNICEF, WHO, UNFPA and other collaborating UN and non-UN organizations, the MOPH is gaining in its ability to reach out to the whole country with services and resources. Coupled with the strengths and capacities developed at the local level, the MOPH and regional/provincial bodies can ensure that services are extended rapidly to the periphery and underserved populations.

Detailed recommendations were given for immediate action and for medium-term program development. A short summary of the recommendations includes:

- Objective of the Safe Motherhood Initiative. We recommend that the MOPH and UNICEF choose, as their main objectives, to:
* increase the proportion of births attended by skilled birth attendants (whether auxiliary midwives, midwives, or female physicians)
* expand access to and the quality of service
- Support national policy development
- Create national clinical practice standards to improve the quality of services
- Data to support planning and monitoring
- Coordination mechanisms to support implementation
- Improve and extend the capacity of existing comprehensive EmOC services
- Focused antenatal care and nutrition services
- Expand and improve postnatal and newborn care
- Improve the linkages between facilities and communities
- Mobilize civil society
- Create a policy for human resource development
- Improve training capacity and resources
- Ensure sustained commodities and improve logistics

Full report in PDF

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Health - Pre/Post Natal Care



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