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


TIMELINE OF THE  FINAL REPORT: From August 2012 to August 2013

Afghanistan has one of the highest maternal mortality ratios (MMR) in the region and the Maternal Mortality Estimation Inter-Agency Group (MMEIG) in 2010 estimates Maternal mortality ratio in Afghanistan 460 per 100,000 Live Births and AMS estimated 327 maternal deaths per 100,000 live births. This means that one in every 50 women in Afghanistan has a lifetime risk of death from pregnancy related complications.  The infant mortality rate stands at 74 deaths per 1,000 live births, while under-five mortality rate is 102 per 1,000 live births according to the Afghan Multi Indicator Survey 2010-2011 (AMICS). The major causes of child mortality in Afghanistan are measles, diarrhoea, acute respiratory infections, malaria and malnutrition. About 30 per cent of under-five deaths are attributed to acute respiratory tract infections and diarrhoea. About ten per cent of people living at lower altitudes suffer from malaria. An estimated 55 per cent of Afghan children are chronically malnourished; 31.2 per cent are underweight; and 33.7 per cent of children and 16.3 per cent of pregnant women suffer from Anaemia. Fewer than 54.3 per cent of Afghan infants are exclusively breastfed, and over two thirds do not receive appropriate and timely complementary feeding. Almost 35 per cent of the population do not have access to health care services.

Rebuilding the health care system after three decades of war and strife has largely been done through implementing a Basic Package of Health Services (BPHS). The Ministry of Public Health (MoPH) reports that 82 % of districts now have a service provider working under a BPHS contract funded by the World Bank, USAID, European Commission and Asian Development Bank. The remaining 18 per cent of districts are served by the MoPH directly. However, the overall coverage of services remains low. The broad range of primary health care services included in the BPHS require more female service providers and it is not possible to find them, particularly in the remote and conflict-affected areas. As a result, services are not reaching most communities not just in the central region, but nationwide.

The scattered population, insecurity, inadequate human resources and funding, are the main barriers to expansion of health infrastructure needed to provide equitable access for all. In some insecure areas, the BPHS contractors could not establish health facilities; they have had to withdraw from other areas; and some established facilities are no longer functioning. Trained people are often unwilling to stay and work in insecure and remote areas.

While Afghanistan had made some progress towards the Millennium Development Goals (MDGs) on maternal and child mortality, it is unlikely to meet any of them by 2015. Large disparities exist between urban/rural, wealth quintiles, genders and ethnic groups, and populations in the high mountains and areas of rugged terrain are particularly disadvantaged.

UNICEF along with WHO (World Health Organisation) and UNFPA (United Nations Population Fund) recognize maternal and new born mortality reduction, as a key priority under the basic services component of the United Nations Development Assistance Framework (UNDAF) in Afghanistan.

Most of the health surveys from Afghanistan have indicated that due to geographic terrains and access to health services and harsh weather, Daikundi is one of the most deprived province of Afghanistan. Keeping in view the mother and child health indicators of Daikundi,  UNICEF and the Ministry of Public Health jointly initiated “the Integrated Maternal, Child Health and Nutrition (IMCHN) Project” in Diakundi province located in the central region of Afghanistan.

The IMCHN project aims to strengthen the following areas of heath care service delivery in Diakundi province:

·         Component 1: comprehensive and Emergency Obstetric and Newborn Care

·         Component 2: establish IMCHN outreach facilities in hard to reach and rural communities

·         Component 3: improve knowledge and skills of health workers on integrated management of newborn and childhood illness

·         Component 4: community utilization and outreach services to families through Community Development Councils (CDC), School Management Shuras (SMS) and women’s literacy classes

3.      Project objective

The overall objectives of the project are:

·        Increase access to, and utilization of, comprehensive and emergency obstetric and newborn care and provide a set of primary community-based integrated maternal and child Health and Nutrition services;

·        Enhance knowledge and skills of service providers on comprehensive and emergency obstetric and newborn care;

·        Increase knowledge and improve behaviour practices related to maternal and newborn care, especially utilization of ante-natal services, recognition of danger signs of pregnancy (mother and new-born) and timely referrals.

4.      Key results achieved

4.1 Improved Basic and Comprehensive Emergency Obstetric Care

Contribution from the Italian National Committee and Nando Peretti Foundation was used to organise the training of facility staff and the provision of new-born kit resulted in the provision of Ante Natal Care to 21,600 women; Post Natal Care to 6,384 women. A total of 180 complicated cases treated for 600 women.
4.2 Integrated maternal child health and nutrition outreach sites in hard-to-reach and rural communities

During the last 12 months (August 2012 – August 2013), the mapping of outreach sites in hard-to-reach locations was done. Essential supplies was provided and 25,507 women and 10,944 children under five has been treated as OPD (Outpatient Treatment). Growth monitoring was conducted for 5,668 children under five. A total of 5,989 children under five have been immunized against vaccine preventable diseases while 12,976 women 15 to 45 years old were vaccinated against Tetanus. In addition, 3,281 pregnant women provided with ANC (Ante Natal Care), 838 women provided with PNC (Post Natal Care) and 1,555 women got family planning education. A total of 2,813 women were dewormed, 58,620 tablet of micronutrient distributed to 1,954 women. Infant and young child feeding training conducted to 116 midwives, nurses, CHSs and vaccinators.

4.3 Community mobilization and outreach services to families

Contribution from the Italian National Committee and, in particular, from the Nando Peretti Foundation, was used to mobilise and train community leaders, village, district councils/Shuras and health and nutrition community support groups on behaviour change communication. A total of 420 Family Health Action Groups (FHAG) were trained on using pictorial counselling flip charts for delivering key messages at the household and community level. Communities were mobilized through community health workers and strengthening of women groups. A total of 25,507 pregnant women have received essential life-saving health awareness through the 420 FHAGs. Each FHAG cover 10-15 families and provide health education and referrals to health facilities for pregnant women with danger signs.

5.      Lessons learned

The importance of community participation in ensuring successful results was reaffirmed. The team effort and commitment right from policy to implementation level is an integral part of IMCHN project. A sustained process of capacity building is necessary for MoPH’s work plans, with adequate financial support.

Unfavourable social and behavioural norms need to be addressed more vigorously for improved prevention of malnutrition, increased family planning services and enhanced male participation in reproductive health care. The temporary family planning methods showed high dropout rate and limited effectiveness in preventing multiple pregnancies and improving maternal health.

Policy decision or incentive scheme is urgently required to ensure that qualified personnel are available to work in the hard-to-reach and remote locations.

Capacity development of government partners, provincial department of public health (DoPH) to effectively implement the IMCHN initiative is an effective way to promote sustainability of the program in future.

UNICEF, thanks to its partners (private, corporate, foundations) will continue the work in the Country for the next years, always in favour of the afghan population.

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