By the time the Taliban regime fell in 2001, Afghanistan had some of the world’s worst health indicators. The under-five mortality rate was estimated to be 256 per 1,000 live births, compared to 92 per 1,000 for the South Asia region. Afghanistan needed to improve its primary health care delivery to decrease its child and maternal mortality rates, particularly in rural areas. Without a viable primary care system, the country was also vulnerable to emergent diseases such as HIV/AIDS and avian influenza that threatened public health.
Building on the work of local and international NGOs already providing some 80 percent of health services at the time the Taliban were overthrown, the Health Sector Emergency Reconstruction and Development Project financed implementation of the Basic Package of Health Services (BPHS) in 11 provinces, in 8 through contracts between the Ministry of Public Health (MoPH) and 8 NGOs and in 3 through direct service delivery by the Ministry of Public Health. To address the shortage of female health workers in remote areas, the project supported the Community Midwifery Education program. In addition volunteer community health workers were trained, new health centers opened, and the quality of care improved. A third party monitored performance. Based on successful results, supplementary financing was provided in early 2006 and additional financing in early 2008.
To meet emergent public health risks, IDA also financed the Afghanistan HIV/AIDS Preventive project. The project targets the epidemic by scaling up prevention programs for people engaged in high-risk behaviors. It also builds national capacity to inform the public at large about how to avoid HIV infection, strengthens surveillance of HIV incidence, maps and estimate the size of groups engaged in high-risk behavior, and supports information and advocacy campaigns to reduce the social stigma associated with the disease. MoPH has signed 11 contracts with national and international organizations to achieve these objectives.
IDA also financed the Avian Influenza Control and Human Pandemic Preparedness and Response Project to keep bird flu from spreading to humans by developing and implementing HPAI (Highly Pathogenic Avian Influenza) prevention and eradication activities. The project’s Animal Health Component is managed by the Ministry of Agriculture, Irrigation and Livestock and its Human Health component is managed by MoPH. Their efforts are supported by a national public information campaign to raise awareness.
Millions of people in rural Afghanistan now have access to primary health care for the first time, as national coverage rates rose from 9 percent of the general population in 2003 to 85 percent in 2008.
- A 2006 study conducted by Johns Hopkins University indicates a 26 percent drop in under-five mortality since 2002.
- In the 11 project provinces, the number of health facilities has nearly tripled from 148 to 421.
- Health service utilization had increased among project area populations from a rate of 0.3 consultations per capita annually at the outset to 1.33 per capita by year’s end 2008.
- Health care for expectant mothers expanded, with the number of deliveries assisted in facility by trained health workers jumping from 6 percent to 23 percent. The number of pregnant women who received at least one prenatal care visit rose from 8,500 in 2003 to 188,670 in 2008. More generally, third-party assessments show that females are more likely than males to use program services, an encouraging sign that gender barriers are not closing off access and that hiring women medical staff and training women as community health workers was having an impact.
- Indicators from the Health Information Management System (HMIS) show signs of progress in child health, with DPT3 vaccination rates for one-year-olds, for instance, increasing from 25 percent in 2003 to 98 percent by the end of 2008.
- The Basic Package of Health Services covered 85 percent of Afghanistan’s 30 million people by year’s end 2008.
- Third-party evaluations show remarkable improvement in health center staffing, equipment, and supply stocks. Absenteeism is virtually unheard of, contrasting markedly with absentee rates of up to 40 percent among public sector doctors elsewhere in South Asia.
- Despite insecurity in some project provinces (Farah, Helmand and Badghis), participating NGOs maintained and even expanded health services. The number of outpatient visits more than tripled between 2003 and 2008 in all three provinces.
- Around 20,000 community health workers—half of them women—have been trained and deployed throughout the country, increasing access to family planning and boosting childhood vaccinations.
- The number of facilities with trained female health workers rose from 25 percent before the project to 85 percent today.
- The TB detection rate increased more than sevenfold from less than 10 percent to almost 72 percent, based on the World Health Organization estimate of an annual sputum-positive incidence of 73 per 100,000.
- By providing virtually free health services, the project widened access to preventive and curative care, reducing the financial shocks from illness that frequently push poor families deeper into poverty.
Some $120 million has been provided in grant financing since 2003, a substantial sum given that estimated total Afghan public sector health care expenditure was $277.7 million in 2008, with about 90 percent coming from external sources.
Beyond direct financial support, IDA worked to strengthen the Ministry of Public Health’s stewardship of the sector, particularly in the monitoring and evaluation of contract management and coordination with its partners. IDA encouraged other donors (for example, the European Community and USAID) to support such efforts.
The Health Sector Emergency Reconstruction and Development Project ended June 30, 2009. In March 2009 the IDA Board approved a new project—Strengthening Health Activities for the Rural Poor (SHARP—with funding of US$30 million for a period of 45 months. SHARP is designed to improve the health and nutritional status of Afghans, focusing especially on women and children and underserved areas of the country. The project supports the government’s Health and Nutrition Sector Strategy, which is the national blueprint for health during 2008–13. Building on the foundation of the program it succeeds, SHARP will finance provision of the Basic Package of Health Services in 11 provinces through MoPH contracts with national and international NGOs in 8 of the provinces and direct delivery of services by the ministry in the remaining 3. To support monitoring and evaluation of service delivery, the project will also engage a third-party agency to conduct annual scorecards for primary health care facilities and hospitals. Lastly, SHARP plans to introduce an innovative results-based financing (RBF) mechanism to extend health center coverage and improve service quality, especially for women and children. Despite the 17 percent increase in institutional deliveries, the number of pregnant women who give birth at a health facility remains low (23 percent), and innovative approaches (like RBF) are needed to persuade communities to take full advantage of available health services.
Health Sector Emergency Reconstruction and Development Project (2003–09)