1. USAID Afghanistan Health Program Improving the health of women of reproductive age and children under 5 years old, especially in rural areas

2. Health Care in Afghanistan: An overview Grim health indicators: Maternal mortality: 1,600 per 100,000 live births (US: 8) Infant mortality: 165 per 1,000 (US: 7) Child mortality: 257 per 1,000, 25% die before age 5 (US: 0.35) Most deaths are from easily preventable diseases & conditions 60% of child mortality is due to CDD, ARI & vaccine preventable diseases 40% of population has no access to health services Human resources: Nearly 40% of Basic Primary Health Service facilities have no female health worker Limited management & service delivery capacity of MOH USAID program goal: reduce maternal mortality, infant mortality, and child mortality.

4. Provinces for grants & other support Underserved districts in highlighted provinces were listed in the RFA

5. Program components Physical infrastructure Service delivery Training & capacity building Use of services Improved health status Economic development

6. Limitations & constraints Security, especially in south & southeast, resulting in: Difficulty in establishing offices & posting staff Additional costs & delays Lack of available human resources, especially female service providers in rural areas Lack of resources in the MOH for the most basic implementation Diversion of BPHS grants budget to cover areas left vulnerable due to donor shift, and delays and shortages of funds by other donors

7. Current USAID Project Health Clinic Construction / Renovation 1-2 OHDACA >2 OHDACA 0 OHDACA 16 11 BHC 5 CHC 15 9 BHC 6 CHC 1 Model clinic 13 7 BHC 6 CHC 7 4 BHC 3 CHC 13 8 BHC 5 CHC 13 11 BHC 2 CHC 80 OHDACA renovations

8. Clinic construction &rehabilitation Clinic construction/ rehabilitation 3 yr target To- date By June Clinics under construction25078152 Clinics rehabilitated370140220 Provincial hospitals rehabilitation 3-40 MOH using an equitable approach with a goal of 1 clinic per 30,000 population working towards 1 clinic per 20,000 population

9. Basic Package of Health Services Maternal and Newborn Health Child Health and Immunization Public Nutrition Communicable Disease Supply of Essential Drugs Disability* Mental Health* * Not currently implemented Helps to prioritize among many health problems (public health) Guides the allocation of scarce human and financial resources to address priority problems (including for NGOs and donors) Provides direction for the rehabilitation of the health care system (start with primary care)

10. Service delivery Service delivery through NGO BPHS grants 3 yr target To- date By June Rural Population (millions)11.1 m6.16.9 m Underserved districts624962 Grant funds committed (USD millions) $56 m$57 m Shortfall Target was the 62 underserved districts out of 154 total districts. Funding is also supporting services in 53 other districts to cover for loss of other donors funding. USAID funding also used to cover WB & EC delays/funding shortages

11. Districts covered by REACH grants

12. Rural Population To Be Covered by Grants in REACH Priority Provinces (population in millions)

13. Training & capacity building Training for: 3 yr target To date By June Community Health Workers/ Traditional Birth Attendants 3,500 9001400 Midwives/community midwives/MDs 1,00050300 Female literacy candidates5,600 Starting 480 Building training capacity: national strategy, curriculum, training centers, clinical training sites Females are 50% target for all provider training Learning for Life literacy program will increase pool of females eligible to become midwives or CHWs Strengthened provincial presence and MOH capacity to improve policy & govern sector

14. Health education & healthy products Planned 1.5 million condoms, 150,000 oral, & 30,000 vials of injectables contraceptives procured & will be on the market by April 2004 Social marketing campaign to emphasize birth spacing Malaria prevention through social marketing and targeted distribution of insecticide treated bed nets Improved skills of retail pharmacists & drug dispensers Key Achievements Prevention of diarrheal disease through national radio campaign - 80 broadcasts on local radio stations Chlorin – Locally produced sodium hypochlorite solution To date 42,000 bottles sold that provide 42 million liters of safe drinking water Launched Number One condom and sold 100,000 in Dec 2003

15. Principles & approaches Full coordination with Ministry of Health Collaboration with and leveraging of other donors Central and provincial level focus Coordination with USG health group

16. Accelerated Program Additional construction Increase training & capacity building activities Expanded service delivery through grants Add support to hospitals

17. (DRAFT) Afghanistan Maternal Health Initiative Saving 120,000 lives January 29, 2004

18. Maternal Death Risk in Afghanistan Risk of maternal death is one of the highest in the world-- 100 TIMES THAT OF U.S. Risk of maternal death in Badakshan of 6500-- HIGHEST EVER RECORDED IN HUMAN HISTORY

19. Badakshan Province has the highest maternal mortality ever recorded Maternal Mortality Ratio (# deaths/100,000 live births) USA 8 Afghanistan1,600 – 2,200 Badakshan6,500 (CDC/UNICEF/USAID Study, 2002) Badakshan Province

20. The Current Situation Fawzia*, 16, illiterate, married at 13, no prenatal care, malnourished delivers at home with only her illiterate mother-in-law in attendance. She hemorrhages and is nine days donkey ride away from skilled care. She dies eight hours after the birth leaving a newborn and two year old daughter. The newborn dies after several days and the girl dies six months later. * An indicative person representative of thousands of Afghan women.

21. USG Initiative to Save Mothers Lives Maternal deaths are preventable –We know what works USG comprehensive program –Basic health services –Roads –Literacy training –Activities to improve the role of women There are no quick solutions –It takes years of commitment and hard work to bring death rates down

22. Expected Results Over 10 Years 100,000 lives saved –35,000 mothers –65,000 newborns 200,000 maternal disabilities due to child birth reduced/avoided –Assuming security and continuing commitment

23. Expanded Maternal Health Initiative: (Red type signifies expanded elements of existing initiative) Construct and renovate rural clinics Provide basic health services in rural areas and launch program to prevent post-partum hemorrhagethe biggest killer Train midwives Link health and education –Incorporate health messages into school curricula and accelerated learning classes for girls –Expand literacy programs to prepare women for entry into community health worker training Build secondary and tertiary roads that link communities to clinics Improve hospital quality (HHS) in provincial hospitals Provide health products through private sector channels and solicit international private sector resources Strengthen administrative capacity for health planning Establish village womens centers and strengthen newly-elected Womens Community Development Councils that facilitate womens access to health information & services

24. Cumulative Lives Saved With Current and Expanded Program Years 2004 2013 100,000 120,000 Expanded Program Current Program KEY

25. With USG-Supported Maternal Health Program Sohaila*, 19, cousin of Fawzia, married at 18, gets iron and folate tablets, tetanus toxoid immunizations and other prenatal care at the newly-built health center from a community healthcare worker. Following delivery at home, she hemorrhages. Her husband who has had community health education transports her on the upgraded feeder road to the community midwife who provides life-saving care to stop the bleeding. She survives. Her newborn daughter survives and enrolls in school at the age of five. * An indicative person representative of what the program is striving toward.

26. Challenges Lack of security in countryside Cultural, geographic isolation of women Need for continuing commitment and support