Stronger health systems Greater health impact Dr. Mubarakshah Mubarak Chief of Party Tech-Serve/MSH Afghanistan Afghanistan Health System

Health Systems Building Blocks Service delivery Health workforce Health information system Medical products, vaccines and technologies Health systems financing Leadership and governance Source: WHO

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numbers of health workers, especially female  Poor data on health  Chronic inadequate quality drugs/damaged and outdated equipment  Inadequate finances  Poor leadership and management; little coordination among partners.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.

4 Afghanistan U5MR and U5MR in the Region

The Ministry of Public Health Response  Stewardship role of MOPH: Contracting out to NGOs  Basic Package of Health Services  Community Focus

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

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

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

Moving toward and integrated health system system Rebuilding the system

Results of improved health systems Increase in functioning health facilities: Year Year Increase in percent of facilities with skilled female health workers: Year % Year % Source: National HMIS of Afghanistan

11 Results of improved health systems Source: MOPH/Johns Hopkins Afghanistan Household Survey, 2006

Improvement in health systems metrics Results of improved health systems Source: JHU Annual Report on BPHS in Afghanistan

Source: UNICEF and JHU Survey Results of improved health systems

Challenges  High infant, child and maternal mortality  Quality of services  Weak hospital sector  Significant salary inequities  High level of dependency on international support.  Insecurity

The things that mattered Focus, focus, focus Consistency in key policies Bold leadership Programmatic: use resources that are there High value placed on monitoring