From Health Relief to Health Reconstruction
in Afghanistan
WHO brief, 5 December 2001
for Afghan Support Group Meeting, 5-7 December 2001, Berlin, Germany
World Health Organization
Organisation Mondiale de la Sante
World Health Organization - Afghanistan
From Health Relief to Health Reconstruction
in Afghanistan
World Health Organization brief, 5 December 2001
SUCCESS OF AFGHANISTAN RECONSTRUCTION WILL BE
MEASURED IN LIVES SAVED AND IMPROVED
GENEROUS SUPPORT FOR HEALTH WILL FOSTER PEACE AND DEVELOPMENT
"Whether in the emergency or the post-conflict reconstruction phase, the most
important thing is to save and improve lives in Afghanistan. This is our number one
goal," declared Dr Gro Harlem Brundtland, Director-General of WHO.
“Significant financial and technical resources are required more than ever before,"
warned Dr Hussein A. Gezairy, WHO Regional Director for the Eastern Mediterranean.
"I truly hope the international community will rise to this occasion to prevent a health
catastrophe in a highly vulnerable population whose suffering continues to be
immense," he said.
Health Relief for the next three months
The priority is to address the major causes of death and illness. In the next three
months, WHO technical and financial resources will be focused on preventing
preventable deaths. In the midst of the triple crisis of the worst drought, the most
intense military action and widespread displacement, immense efforts have been
initiated to prevent deterioration of the health situation. WHO Afghanistan predicted,
based on previous trends, that, in addition to casualties from conflict, respiratory
infections, maternal complications, and diarrheal diseases, would be the killers this
winter due to serious depletion of family resources, poor nutrition, exposure during
displacement, diseases increased due to crowding, and inadequate health care and
referral services. Saving lives would depend on having health workers in the field and
sufficient medical supply in both peripheral and referral centers as well as food, shelter
and security.
WHO Afghanistan Implementation since September 2001:
WHO has almost 200 experienced national and international staff working in and
around Afghanistan who are currently providing technical support to programs and
responding to the emergency situation, especially Strategic Stockpiling, Increasing
Health Services to Vulnerables, Control of Communicable Diseases, and Health
Sector Coordination, which are detailed below.
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Strategic Stockpiling:
During
October 2001, WHO shipped
sufficient Emergency Health Kits into
Afghanistan in October to serve
580,000 people for three months.
While about 32% of the need has
been met, more emergency medical
supplies are still needed, especially
in the North and South where there
are
large
populations
with
inadequate health services as well
as remote and chronically underserved mountainous areas of
Bamyan, Badakhshan and Paktika.
WHO has over 200 Emergency
Health Kits in the pipeline which will
be used during the winter to meet
the health needs of one million
people for a total of six months. Camps and settlements, housing more than one
million IDPs, will also need to be carefully monitored and supported to be sure health
services are adequately provided.
Increasing Health Services to Vulnerables: WHO has provided supplies to keep
basic health services going, filling gaps in external support, including maternal care
among internally displaced populations and other vulnerables, and has provided
supplies to NGO health centers working in areas likely to soon become snow-bound.
In three pilot districts in 8 regions, WHO has continued technical support to health and
development committees in poverty stricken communities. In Faizabad and Kunduz,
in IDP camps and host communities, WHO sponsored water and sanitation projects
have provided safe water supply, latrines and bathhouses.
To prevent excess mortality in Afghanistan this winter, WHO has initiated mobilization
of a health workforce in under-served districts. Those health workers that have no
other external support will be provided with three months supply of drugs for 10,000
population and a three months’ contract to mobilize the outreach teams, distribute
drugs and monitor the outcome. This is a stop-gap measure to cover the winter
emergency until the health sector is rehabilitated.
Health Sector Coordination: WHO has facilitated weekly coordination meetings with
all health sector agencies and provided a library of over 100 emergency manuals to
the Afghan NGO Coordination Center in Peshawar. WHO in collaboration with ICRC
facilitated a training course on medical emergencies in Kabul and has similar courses
scheduled in Herat and Kabul. WHO disseminated new Guidelines for TB treatment
during the Crisis and reprinted translated copies of Guidelines for Case Management
of ARI, Diarrhea, and Malaria for distribution to health workers in IDP camps. The
Manual for Basic Health Kit was translated into Dari and will be distributed along with
World Health Organization - Afghanistan
the 231 Kits in the pipeline. WHO officers are also providing technical support for
ongoing planning and monitoring in the health sector. The WHO rapid assessment of
health facilities in Kabul, completed this week, is part of the process of needs
assessment already initiated to enable evidence-based reconstruction planning.
Control of communicable diseases
and surveillance: Two rounds of the
polio eradication campaign were
conducted
in
all
regions
of
Afghanistan reaching over 5 million
children under age five with each
round. The commitment of WHO
Afghan staff and volunteers in
carrying on the house-to-house
campaigns in spite of general
insecurity is lauded.
Great efforts have been maintained
to overcome the constraints and
continue disease surveillance through
WHO sub-offices. Supply hubs in
Peshawar,
Quetta,
Mashhad,
Turkmenabad, and Dushanbe have
become coordination centers for flow
of information and support to national
staff in Afghanistan. Specimens for 16 cases of acute flaccid paralysis were
successfully transported to the Islamabad laboratory, and an outbreak of falciparum
malaria and cases of diphtheria were reported and responded in collaboration with
NGOs. Focused effort needs to be made with collaboration of all health sector
agencies to pool the available data and streamline the flow to provide the necessary
feedback on the impact of interventions during the Crisis.
Remaining priority needs to reduce avoidable deaths this winter are:
1. Providing essential drugs and supplies, including maternal and child health and
micronutrient supplies, for basic health centers and outreach services in underserved areas and for referral centers near IDP camps.
2. Mobilization and coordination of an additional workforce to meet the needs of IDPs
and under-served areas. See attached map.
3. Inputs for a responsive Health Information System
4. Assessment and coordination of Reproductive Health interventions.
5. Crash training courses for the winter emergency
6. Replacing strategic stockpiles of drugs and supplies and strengthening surveillance
for control of communicable diseases.
7. Ensuring safe water, sanitation and environmental safety in areas of IDP
settlements and host communities
Recruitment of national female coordinators and trainers is especially urgent.
World Health Organization - Afghanistan
The extent to which funds, supplies and workforce needs can be met may very
well be the limiting factors in the extent to which the health sector partners are
able to mitigate the combined impact of drought, displacement and conflict in
Afghanistan this winter.
Preparation for Health Reconstruction
WHO experience in Kosovo and East Timor indicates that planning for the
reconstruction of health sector, as well as for the other sectors, should start now, i.e. in
the relief phase. Health sector rehabilitation must be initiated as quickly as possible,
since equitable coverage and access to care will be major factors of support to local
administration, social stabilisation and peace.
“Aside from relieving suffering, rebuilding the health sector is absolutely crucial
for the future stability and socio-economic development of Afghanistan,” Dr
Brundtland pointed out. “Investing in health, among other social services, is
investing in peace and prosperity.”
WHO humanitarian emergency experts working on the Afghanistan crisis have
indicated that health sector reconstruction must tackle the following five areas to save
and improve lives:
1. Reproductive Health: Every day 45 women die of pregnancy related causes
resulting in more than 16,000 deaths each year. Emergency obstetric care needs to
be made available. Female doctors, nurses and midwives are sorely needed and
existing health workers need further training to assure Safe Motherhood. Accessibility,
availability and quality of comprehensive maternal and neonatal health care services
need to be improved through training of existing health care providers in essential
obstetric care and neonatal care, improved essential midwifery services and improved
referral services that can manage emergency complications as well as through
maximization of antenatal care coverage and tetanus toxoid immunization.
2. Child Health: One-fourth of Afghan children do not live to celebrate their fifth
birthday. Acute malnutrition in children is estimated at 10% and chronic malnutrition is
about 50%, making children all the more vulnerable to disease and death. Routine
immunization needs to continue to be expanded and strengthened and country-wide
catch-up immunization campaigns need to be undertaken. Other childhood killers
such as acute respiratory infections and diarrheal disease need comprehensive
prevention and control measures. Water-borne diseases account for more than 20%
of childhood illness. Current coverage of 23% with safe water and 12% with sanitation
systems needs priority in the reconstruction process. Other interventions such as
community education in hygiene and nutrition and re-training of health workers on
Integrated Management of Childhood Illnesses are also key to improving child health.
World Health Organization - Afghanistan
3. Communicable Disease Control: There are an estimated 72 000 new cases of
tuberculosis each year in Afghanistan. Curing a patient requires DOTS1 over months,
so systems must be put in place to ensure drugs are available and cases are
supervised and cared for during their recovery. Malaria, cholera, measles, typhoid,
meningitis, and hemorrhagic fever occur as deadly outbreaks in different regions of
Afghanistan. The epidemic of leishmaniasis, a disease carried by flies causing sores
which disfigure the face, has spread to more than 80,000 people in Kabul.
Communicable disease control needs a comprehensive environmental, community
and case management approach through integrated primary health care services and
multi-sectoral support.
Disease early warning and response systems need to be put in place and integrated
all across Afghanistan. Health management information systems are in their infancy
and need strengthening with information technology and training, streamlining and
stable support.
4. Mental Health: It is estimated that 10% of a population living in a conflict zone
suffers from mental health problems. Due to the ongoing war for the last 22 years, it is
likely that most Afghans are suffering some level of stress disorder. Residual mental
disease that one would see in any population has not been attended to for years in
Afghanistan as it was mired in conflict, deepening poverty and enveloped by
intolerance. Mental health services urgently need to be re-established.
5. Injuries: People with injuries due to landmines and unexploded ordnance need to
be cared for, both in the immediate, and over the long term so that the disabled are reintegrated into society and able to lead productive lives.
Focusing on Primary Health Care and making it available to all the population, is the
key to effective and efficient health services which can save and improve lives.
Community based initiatives dealing with poverty reduction need to be strengthened
and expanded at the same time as institution capacity building to rehabilitate
Afghanistan.
Reconstruction must ensure that healthcare facilities are completely restored to
ensure the provision of essential services, including referral services for emergency
obstetric care. They need to be fully equipped with supplies, equipment, essential
drugs and vaccines. Health posts need to be established in chronically underserved
areas, and outreach teams need to be increased to reach the far corners of
Afghanistan. There is a critical shortage of health care workers at every level. More
1
Directly Observed Treatment Short-Course.
World Health Organization - Afghanistan
doctors, of every specialty, nurses, midwives, lab and x-ray techs, pharmacists,
dentists, and physiotherapists need to be trained.
Health staff and facilities needed for
reconstruction of health sector,
Afghanistan, 2001
40,000
30,000
20,000
10,000
0
Nurses
Facilities
standard
existing
needed
6,522
823
5,699
Doctors Midlevels & Techs
5,826
3,906
1,920
6,442
2,564
3,878
13,222
4,993
8,229
CHWs
& TBAs
37,500
6,123
31,377
TOTALS
62,990
17,586
45,404
Phases of Reconstruction:
During the 27-29 November Islamabad conference on Preparation for Reconstruction,
three phases of reconstruction after the planning phase were identified.
1. Immediate Interventions – Institutional and organizational support, repairing
structures, delivering essential package of primary health care services, and reestablishing training institutions (Dec 2001 – Sept 2002)
2. Transition Phase – Consolidation: Ensuring quality and equity (June 2002 –
Dec 2003)
3. Longer Term Activities - Expansion – Construction, return of Afghan health
professionals and new graduates (Sept 2002-Dec 2007)
Reconstruction could begin as soon as a government, durable peace, security, funds,
and an agreed long term plan were in place. A detailed needs assessment with
costing and a timeframe should be developed working through the existing
coordination mechanism, National Technical Coordination Committee which includes
all stakeholders, chaired by MOPH. WHO staff and the partnerships they built for
health through the various country programmes, will continue to provide technical
support to the future Afghan government in health policy formulation and country,
regional and sub-regional annual health planning.
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The following are the immediate interventions envisioned by WHO Afghanistan:
1. Needs Assessment - Deployment of rapid health assessment tools to obtain
priority needs and analysis for reconstruction
2. Coordination and collaboration with partners of planning for reconstruction;
advocacy for standards, equity and stewardship.
3. Up scaling collection of health information: capacity building, replacement and
expansion of disease surveillance sites; compilation, analysis, interpretation and
information sharing with stakeholders
4. Up scaling referral centers for emergency obstetric care
5. Initiation of rehabilitation of medical education and health worker training
institutions.
6. Up scaling inputs to capacity building in district health management
7. Reviving programs for prevention and control of communicable diseases.
 Tuberculosis
 Malaria
 Leishmaniasis
 Epidemic response
 Immunization
8. Assuring safe water in five urban centers - Mehterlam, Ghazni, Jalalabad,
Charikar, Shebergan - and villages in Kabul province and rehabilitation of
chlorination systems in major cities
9. Essential survival package in the Western Region to assure health care to underserved communities most vulnerable to displacement
10. Community empowerment through Basic Development Needs program
Conclusion
In Afghanistan, investing in the health sector makes good sense for conflict prevention
as well as for socio-economic development. Empirical evidence suggests that
investing in health can reduce the risk of conflict as well as mitigating its impact.
Through its work in complex emergencies, from Central America to Europe and South
East Asia, WHO has seen health recovery support stabilization and peace. Initiatives
have included humanitarian cease-fires, re-defining health districts along functional
rather than ethnic lines, joint health training of former enemies and cross-community
health initiatives at local level.
“Indications are that much needs to be done in this country whose long-lasting
humanitarian crisis has led to a great accumulation of health needs. The international
community must now seize what is an excellent opportunity to turn the health situation
around in Afghanistan,” Dr. Brundtland emphasized, concurring with Dr. H. A. Gezairy
who stated, “Significant financial and technical resources are required more than ever
before," and called for strong investment in health, at this crucial moment, as a key to
peace and socio-economic development.
World Health Organization - Afghanistan
WHO Afghanistan Plan for Health Relief to Health Reconstruction in Afghanistan
(December 1, 2001 to September 1, 2002)
Activities
Budget (USD)
Health Relief
1.
Providing essential drugs and supplies, including MCH and micronutrient supplies, for
$2,500,000
150 basic health centers and outreach services in under-served areas and for 25 referral
centers for emergency obstetric care.
2.
Rapid assessments, mobilization and coordination of an additional workforce to meet
$700,000
the needs of IDPs and under-served areas.
3.
Inputs for a responsive Health Information System, Monitoring emergency health
$1,026,000
care in eight regions, Analysis and feedback. Publishing guidelines on emergency health
management and control of communicable diseases. Coordination with partners.
4.
Assessment and coordination of Reproductive Health interventions. Support to
$330,000
referral centers for emergency obstetric care. Health education.
5.
Crash training of health workers at each level, doctors, nurses, lab techs and
$145,000
community health workers on emergency medicine and surveillance (about 2800 health
workers, two trainers, male and female) and training materials
6.
Replacing strategic stockpiles of drugs and supplies for control of communicable
$1,300,000
diseases, Strengthening surveillance mechanisms and support to local staff in missions for
emergency response, Laboratory and diagnostic support to detect and confirm outbreaks,
Consultations for outbreak response.
7.
Ensuring safe water, sanitation and environmental safety in areas of IDP settlements
Subtotal
Preparation for Health Sector Reconstruction
1. Needs Assessment - Deployment of rapid health assessment tools to obtain priority needs
and analysis for reconstruction
2. Coordination and collaboration with partners of planning for reconstruction; advocacy for
standards, equity and stewardship.
3. Up scaling collection of health information: capacity building, expansion of disease
surveillance sites
4. Up scaling referral centers for emergency obstetric care and training of health care
providers in essential obstetric care
5. Initiation of rehabilitation of medical education and health worker training institutions in six
regions.
6. Up scaling inputs to capacity building in district health management and institutions
7. Reviving programs for prevention and control of communicable diseases.

Tuberculosis

Malaria

Leishmaniasis

Epidemic response

Immunization
8. Assuring safe water in five urban centers - Mehterlam, Ghazni, Jalalabad, Charikar
(Parwan), Shebergan; villages in Kabul province; and rehabilitation of chlorination systems in
major cities
9. Essential survival package in the Western Region
10. Community empowerment through Basic Development Needs program
Subtotal
Program Support Cost (0.06)
TOTAL
$1,000,000
$7,001,000
$250,000
$100,000
$200,000
$900,000
$3,000,000
$250,000
$1,500,000
$300,000
$250,000
$300,000
$1,200,000
$2,488,000
$6,600,000
$500,000
$17,838,000
$1,490,340
$26,329,340