Islamic Republic of Afghanistan Ministry of Public Health General Directorate of Preventive Medicine Communicable Diseases Control Directorate National Malaria and Leishmaniasis Control Programme
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Health Care SystemOwing to the protracted war, poverty, loss of livelihoods, and the breakdown of health structures, estimates from the AMS 2010 indicate that male and female life expectancies at birth are 62-64 years. For every 1,000 live births, about 3-5 women die during pregnancy, in childbirth, or in the two months after delivery Child mortality continues to be high in Afghanistan although there has been a marked decline in the last decade.The under-5 mortality rate for Afghanistan excluding the South zone for the 2-6 years prior to the survey is 97 deaths per 1,000 births, and the infant mortality rate is 77 deaths per 1,000 births. The national health policy of Afghanistan aims at providing a standardized package of basic services in all primary health care facilities, as described in the Basic Package of Health Services (BPHS)The Basic Package of Health Services includes six standard types of health facilities, ranging from community outreach provided by CHWs at Health Posts, through outpatient care at Health Sub Centers and Basic Health Centers and provided by Mobile Health Teams, to inpatient services at Comprehensive Health Centers, district hospitals and regional hospital. The section below summarizes the services provided by each type of facility. Health Posts: At the community level, basic health services are delivered by CHWs from their own homes, which function as community health posts. A health post, ideally staffed by one female and one male CHW, cover a catchments area of 1,000– 1,500 people, which is equivalent to 100–150 families. The CHWs offer basic curative services, including differential diagnosis and treatment of fever as well as a wide array of communicable diseases. Currently no malaria RDTs are available at health post level Except USAID pilot project in North east provinces (Kunduz, Takhar and Badakhshan. Health Sub Centers: The extremely challenging geography, especially in some parts of the country, the scattered pockets of population, the absence of basic infrastructure such as roads and bridges, ethnic and security issues, etc. all pose difficult questions regarding the establishment of BPHS health facilities based on the number of people covered. A HSC is intended to cover a population of about 3,000-7,000, often residing in remote underserved areas. The HSC is staffed by two technical staff (a male nurse and a community midwife), as well as a cleaner/guard. The HSC provides most of the BPHS services that are available in BHCs. HSCs will refer severe and complicated cases to higher level facilities. The HSCs are not equipped with adequate malaria diagnostic facilities. Mobile Health Teams: Given all the challenges coupled with the scarcity of trained health workers (particularly females), it may not be feasible to establish staffed fixed centers in some remote areas, where the population is scattered and live in small communities. The principal idea of mobile health services is to establish a limited number of mobile health teams in each province by dividing the province into clusters of districts. The MHT ideally has the following staff, male health provider (doctor or nurse), female health provider (community midwife or nurse), vaccinator and driver. The MHTs are unable to offer just clinical malaria diagnostic services. Basic Health Center: The BHC is a small facility offering primary outpatient care, immunizations and Maternal and Newborn care. The services of the BHC cover a population of about 15,000–30,000, depending on the local geographic conditions and the population density (can be less than 15,000 where the population is very isolated). The minimal staffing requirements for a BHC are a nurse, a community midwife, and two vaccinators. Mainly BHC offer clinical malaria diagnostic services but some health facilities are equipped with supplies and equipment for malaria microscopy through GF R5, R8 Project. Comprehensive Health Centers: The CHC covers a catchment area of about 30,000–60,000 people and offer a wider range of services than does the BHC. The facility usually has limited beds inpatient care, and a laboratory equipped with microscopes. The staff of a CHC comprises of doctors (male and female), nurses (male and female), midwives, one (male or female) psychosocial counsellor and pharmacy and laboratory technicians. Irregular attendance by the laboratory technicians due to trainings, illness, commitment to other programme related activities, results weakened laboratory diagnostic services. Furthermore, high patient burden and long waiting lists may also limit access to malaria microscopy at CHCs level. District Hospitals: Each district hospital covers a population of about 100,000–300,000. The district hospital is staffed with a number of doctors, including female obstetricians/gynecologists; a surgeon, an anesthetist, a pediatrician, a doctor who serves as a focal point for mental health: psychosocial counsellors/supervisors; midwives; laboratory and X-ray technicians; a pharmacist; a dentist and dental technician; and two physiotherapists (male and female). HMIS data shows some proportion of malaria cases are diagnosed clinically despite the District Hospitals are equipped with microscopy due to high patient burdens and long waiting lists in the outpatient departments. Review of National PoliciesCommunity-based health careThe full description of the Community-based Health Care Policy of Afghanistan is provided in other documents1, from only some key elements have been extracted and presented. Community-based health care (CBHC) is the basic strategy of the BPHS, providing the context for the comprehensive interaction between the health system and the communities it serves. Its success depends upon community participation and partnership between the community and the health staff. The implementation of CBHC recognizes first that families and communities always look after their own health. Religion and cultural norms and beliefs play an important part in health practices, and families are making decisions to maintain health or care for illness every day. In addition, community members understand and have better information on local needs, priorities, and dynamics. The partnership of health services with communities, therefore, has two objectives: To persuade families and communities to make appropriate use of the health services, promoting health behaviours and social norms; To accept the guidance and involvement of communities in the implementation of health programs, encouraging them to identify and solve their own problems. The following principles guide the policy of community-based health care: CBHC focuses on major health problems for which solutions exist. The lowest-level health worker can provide essential quality of care. Health workers are locally identified and recruited. Health workers are trained incrementally, one skill at a time. An established list of essential medicines and supplies is used. Supervision is regular and supportive. The health worker is accountable to the community. The community makes a financial or in-kind contribution for the services. CBHC is not new to Afghanistan; it existed prior to the many years of war and conflict. However, in this period, Afghanistan has reviewed these international concepts and developed an Afghanistan-specific form of CBHC, which was adopted by the Ministry of Health (following the national conference on CBHC of September 2002). The policy on CBHC in Afghanistan is as follows: The community must play the prime role, as community participation is required to ensure both the availability of services and their sustainability. CBHC and related CHWs are community-based and community-owned programs, receiving essential technical and material support from both NGO and MOPH health services channelled through community structures. These channels are often formalized by the establishment of a community health committee made up of representatives from various parts of the community. All levels of the health care system should receive orientation to the principles of CBHC and be trained in responsiveness to referrals from the communities and other responsibilities. The community must fundamentally agree and adopt the standardized CHW job description, with agreement to both preventive and first-level curative activities. Quality training using sequential tasks will take place as close to the community as possible, with national CHW standard curriculum guidelines defining needed competencies but training methods being locally determined. Adequate supervision is to be assured before recruitment and training, preferably provided by the person who does the training. The closest health facility will regularly provide CHWs with a standardized kit of medicines and essential supplies adapted to the local situation and approved for CHW activities. Compensation must be sustainable, with full-time work to be paid and part-time work compensated only by performance-based incentives. When possible, traditional compensation and in-kind contributions will be maintained. Community mechanisms for identifying needs should include also private-sector providers, both traditional and modern. The Afghan CBHC system is shown in the figure below, which emphasizes the dynamic nature of the system. 
The work of the CHWs is overseen by the Shura-e-Sehi. There are two type of Shura-e-Sehi related to the CBHC Program of Afghanistan: Facility Shura The facility shura works with facility staff to assure the relevance of services to community needs, and provision of good quality of care and patient satisfaction. Community Shura-e-Sehi The community shura provides direction and support to all health-related activities in their community. They select, support and supervise the CHWs in the community; they monitor the community with the CHWs to be able to encourage families to make full use of preventive health services including outreach services; they provide guidance in the adoption and promotion of new behaviors and social norms. The CHW are identified by the community, among those resident in the area. They are required to be at least 20 year old (and maximum 50 years). Basic literacy is an advantage, but is not essential for the CHW. Women are encouraged to volunteer and be trained as CHW, as the MOPH policy requires that at least 50% of the CHW trainees are women. The CHWs are volunteers and work part-time. They should be compensated for the services they provide through policies and procedures that are decided locally by communities and the organization that supervises the CHWs. Such remuneration may be in cash or kind, or non-monetary recognition. The CHWs should be compensated for all legitimate expenses (transport and food) when working outside their community. Specifically, approved under this BPHS revision (2009):
Afs100 per month for routine work travel Additional expenses (Afs50) for approved tasks, such as accompanying a suspected TB patient to a facility with a laboratory, or participation to the National Immunization Days and other campaigns. The CHW is accountable to the local Shura for performance and community satisfaction and technically accountable to the community health supervisor (CHS) assigned by authorities from the nearest health facility. Government will not pay salaries to CHWs, and does not recommend donors and NGOs to do so. The two types of communities with little or no coverage with CBHC are the urban populations and the nomadic communities. Only few projects have implemented to evaluate the feasibility of different approaches to provide BHC for these populations. Malaria treatment guidelines and management of feverThe MOPH of Afghanistan has updated the national malaria treatment guidelines and adopted Artesunate + Sulfadoxine/Pyrimethamine as first line treatment of P.falciparum uncomplicated malaria and Chloroquine for P.Vavix uncomplicated malaria but the pregnant women in first trimester with confirmed plasmodium falciparum will be treated with quinine at facility level (see figure 6 ) and Second and third trimester with SP plus AS and for P. vivax with chloroquine. The adoption of ACTs as antimalarial treatment policy was endorsed in the EMRO region in 20032. Afghanistan’s treatment policy was updated in 2009, approved and endorsed by MoPH in October 2010 and will be implemented in all health facilities in January 2011 with the support from the GF R8 grant. Chloroquine + primaquine are the standard treatment of P. vivax malaria, while chloroquine is still recommended for the treatment of clinical (unconfirmed) malaria. Artemether /artesunate/IM is the recommended treatment for the management of severe falciparum malaria at health facilities level (HSC, BHC and CHC) as first dose then patient should refer, If referral is not possible, treatment with artemether/ artesunate should continue until the patient is able to receive the medication orally according to the National Malaria Treatment Guideline, Quinine is recommended for treatment of severe falciparum malaria at hospital level. Parasitological confirmation of malaria with microscopy is recommended, but since access to laboratory services is limited, the great majority of cases are still treated on the basis of clinical diagnosis alone. In order to implement correctly the CBMM strategy, aiming at providing universal access to parasitological confirmation of malaria, specific algorithms for diagnosis and management of fevers suspected as malaria (fever without any obvious cause) will be developed and tested. The standard algorithms provided by WHO (see Figure 3 & 4 below) and Malaria Flow Chart At Health Post Level for the treatment of pregnant women according to the National Malaria Treatment guideline of NMLCP in page 55, will be reviewed and adapted to the specific needs of Afghanistan and also it is requested from reproductive health department of MoPH to add it in ANC guideline. 
Figure _3. Algorithm for managing uncomplicated malaria in health facilities 
Figure _4. Algorithm for managing common childhood illness at community level, as part of the Community IMCI strategy3 Antibiotics, ORS are already part of the CHW kits in Afghanistan and the implementation of CIMCI has already started in several provinces. The CBMM will be fully integrated with the Community IMCI, promoting its implementation for the management of referrals and treatment of malaria, pneumonia, diarrhoea and non-malaria fevers at community level. The introduction of RDT will enable early identification of the non-malaria fevers, which, due to the relatively low prevalence of malaria in most parts of Afghanistan, do represent the large majority of febrile illnesses. It is anticipated that, in addition to identifying cases, this will translate into improved targeting of treatments. Currently, under clinical diagnosis, it is likely that 99%-80% of cases are inappropriately treated with anti-malarials when, in fact, they do not have malaria Directory: Content -> Media -> Documents Media -> Black Watch – press and marketing pack Contents Media -> 2015 chevrolet silverado 1500 New for 2015 Media -> Citizens Theatre, Glasgow: Wed 23 – Sat 26 March Macphail Theatre, Ullapool Media -> Epa vehicle class Media -> 2016 chevrolet tahoe vehicle highlights Media -> 2015 chevrolet corvette stingray new for 2015 Media -> Opel History 1900-1909 Documents -> Islamic Republic of Afghanistan Ministry of Public Health General Directorate of Preventive Medicine and Primary Health Care, National Malaria and Leishmaniasis Control Programme Draft National Malaria Strategic Plan Download 5.6 Mb. Share with your friends:
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