Implementation of Community Based Integrated Package in Daikundi Province (Afghanistan) for the Reduction of Maternal and Child Mortality

Project location: Afghanistan, Daikundi Province
Project start date: July 2012 - Project end date: December 2013
Project number: 2012-024
Beneficiary: UNICEF


The protracted conflict and the humanitarian crisis have resulted in Afghanistan having some of the bleakest human development indicators in the world. The country has the highest Maternal Mortality Ratio (MMR) of 1,400/100,000 live births. Nine in 10 rural women deliver at home, without skilled birth-attendants and access to emergency obstetric care. Infant mortality is 134 per 1,000 live births, while under-5 child mortality is 199 per 1,000 live births. Over half of all children and pregnant women are malnourished and anaemic.

The major causes of child mortality are measles, diarrhoea, acute respiratory infections, malaria and malnutrition. Fifty-one of every 1,000 children born in Afghanistan die from diarrhoeal diseases before their fifth birthday. An estimated 54 per cent of Afghan children are chronically malnourished, 40 per cent are underweight, and 71 per cent of children and 65 per cent of pregnant women suffer from iron deficiency.

UNICEF in 2010 has initiated implementation of Community Based Integrated Package of Services in four of the most under-served provinces of Afghanistan: Daikundi, Badghis, Nooristan and Nimroz. In 2011 and 2012 UNICEF is working to cover all the four provinces furnishing good services to our beneficiaries and to expand the intervention to other 10 provinces.
The package follows the continuum of care approach from newborn period to infancy, childhood, adolescence, pregnancy and post-pregnancy periods. It includes all the major evidence based interventions pertaining to health, nutrition and hygiene.
In the framework of the collaboration with the Nando Peretti Foundation, UNICEF would like to focus its actions on the province of Daikundi that, for different reasons, need its intervention.

Daikundi has a population of 477,544 dispersed across a mountainous terrain with low availability of drinking water, electricity and road access.
It is one of the 34 provinces in Afghanistan with a total land area of 22,019 square kilometres, which is 2.68% of Afghanistan. Daikundi is a central highland located 2,400 meters above sea level. Thanks to its geographical situation (protected by mountains), Daikundi is a safe zone and national/international community is able to work in peaceful conditions. This is the reason why a big number of UN agencies work in this pilot region in very close collaboration testing the "UN delivering as one" approach. Working together UNICEF aims at avoid duplication, be more effective and strengthen its impacts.
The access to health services is very low due to geographical inaccessibility and poor existing infrastructure of health services and due to the low availability of trained health care providers especially female.
The rates of maternal and neonatal mortality, prevalence of diarrhoea, pneumonia and malnutrition are high comparable to other provinces of the country.
The province of Daikundi has 9 districts namely Gizab, Gitti, Ishtarlee, Khadir, Miramor, Nilli, Shahristan, Sangi Takht and Gujran. Five districts have been covered by the project in 2011; by 2013, UNICEF aims to cover all nine districts.
In the province UNICEF can count a total of 39 public health facilities and 226 Health Posts. Each Health Post has a male and a female Community Health Worker (CHW) who are responsible for health education and providing some key preventive medicines to about 100 families. Each female CHW identifies 10 influential women who are in charge of catering for 10 families each. The women identified form a Family health Action Group (FHAG) which helps in health and nutrition education to families.

The Implementation of Community Based Integrated Package heavily relied on services extended by the mobile outreach and the CHWs and FHAGs.
Thanks to the support of the Nando Peretti Foundation, UNICEF wants to strengthen its presence in Daikundi and continue the work started in 2011. It aims at providing the essential financial and technical support to implement the integrated community based package in all nine districts of Daikundi province by 2013.
This will benefit a population of 43,643 children under 5 years, 17,458 pregnant and lactating women and 40,000 adolescents.

In 2011, through collaboration with various provincial government departments, in the focus province of Daikundi UNICEF could achieve important results. Some dates:
1. 36% (9,100 out of 25,278 targeted) of pregnant women, 36% (7,280 out of 20,222 targeted) of new born and 36% (9,100 out of 25,278 targeted) of under five years old children accessed /utilized quality community based Integrated maternal/newborn, child health & Nutrition services;
2. 20,921 women received Antenatal Care
3. 10,017 pregnant women received micronutrients
4. 1,187 pregnant women with complications had safe delivery
5. Lives of 152 new-born with low weight saved
6. 4,203 children with diarrhoea treated
7. 1,350 families have access to safe drinking water approximately 1000 families gained awareness on good hygiene practices and use of sanitary latrines.

The program "Implementation of Community Based Integrated Package" has 4 main focus area of intervention:
- Planning mobile outreach teams to reach all un-covered areas at least 4 times a year
- Delivering an integrated community- based package of health and nutrition services
- Strengthening Community Health Workers (CHW) with counseling skills and train the Family Health Action Group (FHAG)
- Strengthening health facility care by training the existing providers.

The Interventions of Community Based Integrated Package includes different but correlated activities:
1. Promotion of skilled or improved ante-natal care attendance during pregnancy, delivery and immediate post-partum. All pregnant and lactating women will be provided multiple micro-nutrient supplementations through community, facilities and outreach services.

2. Improving neonatal care through birth preparedness messages and post-natal care. Special care package for low birth weight babies will be implemented through additional visits of community health worker and outreach services.
3. Promoting breastfeeding and complementary feeding: Every effort to encourage and support exclusive breast feeding will be done by mother support groups, CHWs and facility/outreach staff who will educate the mother, her husband, in-laws and other family members to the importance of exclusive breastfeeding for the first 6 months of life and promoting timely and adequate complementary feeding from six months onwards.
4. Improving immunization coverage of mothers and children. In line with the national immunization program, immunizations therapies and vaccines will be administered to all infants during theirs firsts 9 months of life.
5. Supplementation of Vitamin A to children 6-59 months.
6. Integrated management of sick children: integrated approach to management of sick children. It allows for assessment and treatment of the main causes of mortality: diarrhoea, pneumonia, malaria and other febrile diseases, as well as malnutrition (therapeutic feeding units), and for prompt referral where necessary. Commodities like de-worming tablets, ORS, zinc, paracetamol and antibiotic syrups will be provided through the outreach teams.
7. Focus on adolescent health including provision of iron-foliate tablets and de-worming tablets through joint program with education sector.
8. Promotion of hand washing and sanitation through CHWs in collaboration with WASH sector.

In general, UNICEF works with others partners (local and international) to implement programs. In Afghanistan, partnership with NGOs is compulsory because of the country situation.
The entire budget for Health services is provided in Afghanistan by the International Community (Budget Support). Government and international partners (the most important partners working in the sector are World Bank, USAID, EU, UNICEF) met each other's every 3 months in the BPHS group (Basic Package Health Services) to identify strategies and follow-up activities. The Government led the sector but, because of the difficult context, it is not completely in charge of service delivering.
The Government guarantees directly the delivering of health services in only 3 provinces of the Country.
In the rest of Afghanistan, 31 provinces, the health services are delegated to NGOs (the majority is local) which are selected and contracted by the government to furnish services and medicines.

UNICEF and its local partners are building a partnership to guarantee community mobilization and expanding out-reaches services to the under-served areas. These include also the mapping of under-served areas and the identification of village clusters where outreach camps can be arranged.
The out-reach camps provide the basic services for health and nutrition education, immunization, ante-natal and post-natal care, family planning and nutritional screening of under-five children. Treatment is also provided for common ailments with provision of essential drugs and basic medical equipment.
Besides, in the out-reach camps, UNICEF schedule and realise training activities for the health service providers.
UNICEF and its partner worked and are working to strengthen CHWs and FHAGs capacities through different trainings on, for instance: pictorial counselling flip charts, infant and young child feeding, nutritional screening and referral and community led total sanitation.
UNICEF is also going to realize capacity building activities for Hospital health service providers through the following trainings:
- Integrated Management of Childhood Illnesses (IMCI)
- Emergency Obstetric Care (EmOC)
- Emergency Triage, Assessment and Treatment (ETAT)
- Newborn care.
In the implementation of capacity building activities for related health service providers, UNICEF uses Ministry of Public Health standard guidelines.

The project, which received a grant from the Nando Peretti Foundation, will contribute to the overall Program Component Result of the country program, "Child and maternal mortality are reduced through more equitable access to quality health, nutrition and WASH (Water, Sanitation, Hygiene) services."
The Intermediate Result of the project is to ensure that:
1. "In target province of Daikundi, 75 per cent of pregnant women, newborns and under five children, have access to and utilize quality, community-based, integrated minimum package of health, nutrition and WASH services by 2013."
2. Specific-expected results and expected outcomes contributing to the results:

The project results will be focused on the main national health indicators focusing on maternal and neonatal health. Meticulous monitoring of the program activities to ensure the delivery of quality services will be done through regular direct supervision and analysis of data. The expected result of this project is obviously related to the main objectives, the following results expected through end of the project:

- The capacity of 24 health workers and 489 community health workers built to manage sick children using standard Integrated Management of Childhood Illnesses approach.
- 5,854 out of 14,660 pregnant women immunized against tetanus during their child bearing age (15-45y) in the defined villages by end of project (TT2+)
- 29,320 out of 73,300 under 5 children immunized against preventable disease of childhood (Penta 3)
- A community based micronutrient supplementation services for pregnant women in all villages established in the defined geographical area by end of project
- 29,320 out of 73,300 child bearing age mothers provided with relevant information and basic services regarding health, hygiene and nutrition
- 29,320 out of 73,300 child bearing age mothers thought how to behave to their young children and evaluate changes in their health.
- A recording and registration system for all child bearing age women, pregnant women, newborn and under-five children established.
- 5,864 out of 14,660 pregnant women provided Antenatal Care, Postnatal care and timed referral for institutional delivery.
- 5-10 Family Health Action Groups (FHAG) per health post established in 2 districts (Shahristan and Sangtakht Bandar).
- 196 out of 489 CHW's trained on counseling flip cart at the community level.
- 90 out of 489 CHWs trained on IYCF (Infant, Young, child feedin) /malnutrition at the community level.

Target Population

The project aims to reduce the maternal, newborn and under-five mortality rate in Daikundi province and therefore all the mentioned groups are the target population of the project:
- Total 29,320 out of 73,300 Child Bearing Age Women
- Total 5,864 out of 14,660 pregnant women
- Total 29,320 out of 73,300 under-five children
- Populations at risk of ill health, such as nomads and ailaq

Totally 146,600 out of 366,500 the population of Daikundi would benefit from the project activities.

In order to be able to monitor and measure the outcomes, it is essential that program objectives are SMART (Specific, Measurable, Achievable, Realistic and Time). As well as the Outputs and the results of the project, partner NGO utilizes tools that have been developed for the purpose of monitoring and evaluation.
These monitoring strategies help the supervisors to assess whether the theory taught has been understood and is resulting in appropriate practice. It is also an opportunity to address gaps in knowledge and to correct any inappropriate practice. Each month the supervisor completes a monthly planning form where they schedule their supervision trips/ meetings. The project will be regularly monitored: UNICEF central region and country office organize monitoring missions. UNICEF could also conduct and external evaluation (HHS - Household survey) at the end of the project to evaluate the outcome of the project.UNICEF is the largest global organisation working specifically for children and their rights.
Created in 1946 and established in 1953 in Permanent Agency of the United Nations, for over 60 years UNICEF has been the world's leading organisation for children, working to help them survive and thrive from early childhood through adolescence. Today, with its strong presence in 190 countries with regional offices, country offices and national committees, UNICEF is the world's leading advocate for children. Reach, expertise, access, innovation, efficiency, resolve, these are the values that guide its work making UNICEF unique and the best organisation for children.

UNICEF is a global humanitarian relief organization providing children with health care and immunizations, clean water, nutrition and food security, education, emergency relief and more. UNICEF's unrivalled access, expertise and influence with governments throughout the world has allowed it to save more children's lives than any other humanitarian organization.

Since its inception, UNICEF has strived to reach as many children as possible with effective, low-cost solutions to counter the biggest threats to their survival.
In countries where there is overall progress, but a widening gap between rich and poor, UNICEF is doubling its efforts to reach the poorest 20%, where preventable deaths are most concentrated.
- UNICEF provides child immunizations and vaccinations to more than half of the world's children.
- UNICEF provides families with clean drinking water and sanitation, helping nearly 1.8 billion people gain access to safe drinking water.
- UNICEF helps protect children against malaria; in 2008 UNICEF distributed more than 19 million anti-malaria bed nets.
- UNICEF provides nourishment to prevent malnutrition; in many famine-ravaged countries UNICEF is the main provider of ready-to-eat therapeutic foods that can bring children back from the brink of starvation.
- UNICEF participates in the fight against AIDS by caring for children affected by AIDS and ensuring that infected pregnant women get the drugs they need to prevent transmission of the virus to their babies.
- UNICEF works to protect children from abuse, aiming to stop child exploitation and trafficking.
- UNICEF strives to provide access to a quality education for all children.

UNICEF has saved more children's lives than any other humanitarian organization and is not daunted by war or conflict, disaster or disease, geography or logistical complexity.

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