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Stronger health systems
Greater health impact
Dr. Mubarakshah Mubarak
Chief of Party Tech-Serve/MSH Afghanistan
Afghanistan Health System 2002-2010
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Health Systems Building BlocksSe
rvice
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Health
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ealth
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Med
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Source: WHO
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Afghanistan’s Broken Health System pre-2002
Weak health systems Inequitable distribution of health
services; clinics and hospitals damaged by war, earthquakes and neglect
Insufficient numbers of health workers, especially female
Poor data on health Chronic inadequate quality
drugs/damaged and outdated equipment
Inadequate finances Poor leadership and management;
little coordination among partners.
Poor health status Life expectancy: 47 for men
and 45 for women One in every four children
died before the age of 5 Maternal mortality
estimated at 1,600 per 100,000 live births, one of the highest ratios in the world.
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4
Afghanistan U5MR and U5MR in the Region
0
100
200
300
400
1960 1990 2002 2006
Afghanistan
South Asia
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The Ministry of Public Health Response
Stewardship role of MOPH: Contracting out to NGOs
Basic Package of Health Services
Community Focus
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Rebuilding the system: Stewardship
Service Delivery: all services through NGOs
Health Workforce: capacity building included in NGO contracts; civil Service reform
Information: evidence-based decision making for policy formulation
Medicines/Vaccines/Technologies: centralized international procurement of quality/low price pharmaceuticals; few stock outs at facility level
Financing: by donors and government
Leadership & Governance: leadership development for NGOs and public sector
Increase of coverage to entire country
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Rebuilding the system: BPHS
Service Delivery: expanded
Health Workforce: standardized staffing requirements
Information: standard indicators
Medicines/vaccines/technologies: limited set of essential
Financing: contracting all BPHS out via NGOs
Governance & leadership: close coordination between NGOs and MoPH/partners
Reduce maternal and child mortality
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Rebuilding the system: Community focus
Service Delivery: Defined/focus TOR for CHWs
Health Workforce: 21,000 CHWs ( male and female)
Information: use of community maps; pictorial tally sheets; linked to HMIS
Medicines/vaccines/technologies: CHWs provide DMPA and ORS/zinc, and cotrimoxazole
Financing: volunteers, non cash incentives
Governance & leadership: policy and Strategy, NGOs development on CBHC
Community as Foundation for Health
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Moving toward and integrated health system system
Rebuilding the system
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Results of improved health systems
• Increase in functioning health facilities:• Year 2002 - 496 • Year 2009 - 1780
•Increase in percent of facilities with skilled female health workers:• Year 2002- 24.8% • Year 2007 - 82%
Source: National HMIS of Afghanistan
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11
Results of improved health systems
0
5
10
15
20
25
30
35
2003 2005 2006
% of pregnant women receiving care from a skilled provider
% of women delivering assisted by a doctor, nurse or midwife
Source: MOPH/Johns Hopkins Afghanistan Household Survey, 2006
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Improvement in health systems metrics
50556065707580859095
%
Availability ofEquipment
Availability ofDrugs
Availability ofFamily Planning
2004 2005 2006 2007 2008
Results of improved health systems
Source: JHU Annual Report on BPHS in Afghanistan
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257
165191
129
50
100
150
200
250
300
Under Five Mortality Rate (per1000 live births)
Infant Mortality Rate (per 1000live births)
2000 2004/5
Source: UNICEF and JHU Survey
Results of improved health systems
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Challenges
High infant, child and maternal mortality
Quality of services Weak hospital sector Significant salary inequities High level of dependency
on international support. Insecurity
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The things that mattered
Focus, focus, focus
Consistency in key policies
Bold leadership
Programmatic: use resources that are there
High value placed on monitoring