1. Stronger health systems Greater health impact Dr. Mubarakshah Mubarak Chief of Party Tech-Serve/MSH Afghanistan Afghanistan Health System 2002-2010

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

3. 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numbers of health workers, especially female  Poor data on health  Chronic inadequate quality drugs/damaged and outdated equipment  Inadequate finances  Poor leadership and management; little coordination among partners.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. 4 Afghanistan U5MR and U5MR in the Region

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

6. 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

7. 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

8. 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

9. Moving toward and integrated health system system Rebuilding the system

10. Results of improved health systems Increase in functioning health facilities: Year 2002 - 496 Year 2009 - 1780 Increase in percent of facilities with skilled female health workers: Year 2002- 24.8% Year 2007 - 82% Source: National HMIS of Afghanistan

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

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

13. Source: UNICEF and JHU Survey Results of improved health systems

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

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