How Conflict-Ridden Afghanistan Improved Its Health In 10 Years

New Delhi: After the fall of the Taliban in 2001 and as a country recovering from conflict, Afghanistan had some of the worst health indicators in the world. More than one-in-two (54%) children under five were stunted and around four-in-ten (39%) children were underweight in Afghanistan in 2004.  It ranked 181/182 on the human development index, ranked the worst in stunting prevalence across the world and its under-five mortality was 257 per 1,000 live births.

In just 10 years, despite conflict and widespread poverty, Afghanistan made significant improvements in its health indicators: Under-five mortality reduced 29%, stunting declined from 54% in 2004 to 40% and underweight children declined from 39% to 20% in 2013.

Coverage of several maternal care interventions increased: Antenatal care--care during pregnancy--increased from 16% to 53%, births assisted by a skilled birth attendant from 14% to 46%, and births in a health facility from 13% to 39%. Childhood vaccinations doubled from 40% to 80% during this time.

The reduction in stunting has a lot to do with the health ministry’s focus on early breastfeeding and convergence of various ministries and aid agencies to achieve the goal, according to Homayoun Ludin, director of public nutrition, Ministry of Public Health.

Ludin, 40, was in New Delhi recently for a conference on “Critical Public Health Consequences of the Double Burden of Malnutrition and the Changing Food Environment in South and South-East Asia.” Excerpts from the interview:

When did Afghanistan start the campaign to reduce stunting?

It started in 2002, and we established the public nutrition department under the ministry of public health. For a few years, there was no clear understanding of how to achieve the targets. Then we organised one of the nutrition conferences in Kabul--South Asia Breastfeeding Forum in 2006.

Our minister and deputy minister and those involved in nutrition were mobilised on how to achieve specific actions, especially those which were well-studied like breast feeding, child feeding, complementary feeding and maternal feeding and initiatives like baby-friendly and mother-friendly 'huspatal' [hospital].

Those actions discussed in 2006 started a new movement. We then developed a declaration and started working on that.

This year, our President expressed his interest in reducing child stunting. We have looked at two concepts--reduction of stunting and wasting through poverty reduction and on nutrition in the first 1,000 days of life.

Our first lady also gave a speech on the importance of breastfeeding to national channels showing commitment.

How did you get ministries to converge on the topic of nutrition?

When we did not achieve our goals as we wanted or expected to achieve, we decided this is not just a health issue, and we need to involve other ministries as well. We developed another agenda--food security and nutrition--which is now shared with the general director of the council of ministries, which is the coordinating body of all ministries.

They have a council of ministries and got 17 relevant ministries involved under ‘Afghanistan Food Security and Nutrition’ Agenda.

After the chief executive officer (CEO) of our government released the names for all these ministries, we had a big gathering in 2017. During the day, ministries were called on to develop their plan. Each month, they meet and prepare a plan. We have another meeting called the executive committee meeting and a high level steering meeting in six months where all ministers of the 17 ministries under the leadership of the CEO review the action points of each executive committee for the next six months.

Each ministry has specific terms of reference under nutrition and we have a specific advocacy meeting for each ministry. For example, ministry of rural rehabilitation and ministry of water and sanitation all have a part to play in nutrition. The ministry of education has integrated nutrition topics into the curriculum. The ministry of higher education has established nutrition departments in universities.

As most people follow religious leaders, we have close coordination with the ministry of religious affairs, which work with religious leaders on the importance of  nutrition taking references mentioned in Koran. Now they [religious leaders] speak about nutrition in their speeches during different occasions. It shows the coordination and multi-sectoral approach.

When did you notice improvements in stunting?

We had the first national nutritional survey in 2004, and the second one after 10 years in 2013.

In 2004, the stunting rate was 54%; after ten years, in 2013, it was 40%; the same thing in exclusive breastfeeding: It was 30%, and it is now at 58.4%. So, breastfeeding plays a role in reducing stunting.

Increasing the food security situation as well as sanitation and water are linked with the  reduction of stunting.

So, nutrition is not something to achieve in one year or six months. It takes effort, it’s a long process. Therefore, we conduct the survey after ten years or seven years.

We are conducting another survey, which is a household-level health survey, next year  where we will see stunting or wasting and exclusive breastfeeding. We have four indicators, and will get the results of the survey by the end of 2018.

Why did the ministry focus on breastfeeding?

As breastfeeding is fundamental for health and nutrition, whenever a mother is planning to have a baby, we train mothers about the importance of their [own] health. Religious leaders back the members in their community to support the efforts of mothers to have healthy babies.

Prophet Mohammed in Koran says that a strong Muslim is better than a weak Muslim. So, we say “if we support mothers, strong baby will come to the world”.

First, we support women during the nine months of pregnancy, and we expect well-nourished baby to be around 3.5 kg during pregnancy. After two years, we expect appropriate height and weight… we have kept 86 cm height as our target after the completion of two years.

Breastfeeding is very important for the baby to be well nourished, and it is equally important for mothers to prevent breast cancer and ovarian cancer. We are supporting maternal nutrition during six months of exclusive breastfeeding when there is no chance of treating babies for anaemia.

We are supporting mothers to have nutritious food, and to be supported by family and religious leaders to eat appropriate food.

Is it difficult to talk about breastfeeding in Afghan society? Do women accept you, as a male, talking to them about breastfeeding?

In our society, whenever a man is talking, they [people], and even religious leaders, accept it. Just a few weeks back, I made a presentation to 200 religious leaders, including representatives from the ministry of religious affairs. I spoke at length about six verses of Koran [that support breastfeeding], and they accepted it.

When men come for Friday religious gatherings, they [religious leaders] convey this to them for their wives because it is difficult to speak to women since they don’t come out of the house or visit health facilities even when there are problems.

It is not direct to the women, directly to the women, but to their husbands or religious leaders. In case there are [health] problems, there are female nutritional counsellors at every facility.

What were your observations after visiting a few anganwadis (daycare centres) in India. What are the gaps that you noticed?

The important thing is creating the demand, and the second is supply. If we don’t have supply, then creating demand is not solving the problem.

If we are monitoring growth or weighing a child or measuring the length of the baby, we need to inform mothers that the baby’s height should be 86 cm after six months. If your baby is less than 86 cm after six months, your baby is malnourished.

When the mother asks what she can do, this is the time for counselling, to ask if they still breastfeed the baby and can I (health worker) see or observe.

They (health workers) observe if there is attachment or position problem. If there is not enough or appropriate family support, we support the mother in front of the family so that change can happen.

There is going to be a nutritional counsellor in every health centre in Afghanistan. The hiring for 18 provinces [of 34] is almost done.

What is zero budget and how do you work despite financial limitations?

We have limited financial resources in our country. So, we have used the available resource, which is human resource.

We have 2,000 health facilities and 100 hospitals. To train our staff for each hospital, we need $8,000-10,000 for one batch. If you multiply $10,000 by 100 hospitals, you can see that it is expensive.

Therefore, we train two trainers for each hospital and ask them to train their own staff--in three days, one day or two hours each day for a week during lunch break. This is what we call zero budget.

What is the baby-friendly hospital initiative?

It is mainly in two parts: Whenever a baby is born in the hospital, we will tell the mother to start early initiation of breastfeeding within one hour since support is available. A midwife or nurse will support the mother, and if there are issues like attachment or position issues, they can help them.

Also, no promotion of any kind of breast milk substitute is allowed in our hospitals. No advertisement, no free gifts, brochures or posters are allowed.

We counsel the mothers about early initiation of breastfeeding and each mother coming to the hospital is made aware about the importance of breastfeeding.

Till now, 80 hospitals have been certified as baby-friendly hospitals.

How did you work with different aid agencies that have their own focus areas? How did you collaborate with them?

We work with both foreign and local agencies. While some of them have already received funds, some are looking for funds and developing proposals.

When we draft the national annual plan, we ask everyone to send us their plans and activities. We invite them for a meeting and discuss each point.

For example, in a community, if there are six organisations with their own concept of community-based nutrition, we integrate all of them and bring them under one umbrella and prepare one package and implement it.

Each has a part to play in the plan--water and sanitation, family planning, nutrition--which they show to their donors. The government is facilitating, coordinating and leading the process.

We are not creating problems for agencies but giving them priorities.

(Yadavar is a principal correspondent with IndiaSpend.)

We welcome feedback. Please write to respond@www.health-check.in. We reserve the right to edit responses for language and grammar.

New Delhi: After the fall of the Taliban in 2001 and as a country recovering from conflict, Afghanistan had some of the worst health indicators in the world. More than one-in-two (54%) children under five were stunted and around four-in-ten (39%) children were underweight in Afghanistan in 2004.  It ranked 181/182 on the human development index, ranked the worst in stunting prevalence across the world and its under-five mortality was 257 per 1,000 live births.

In just 10 years, despite conflict and widespread poverty, Afghanistan made significant improvements in its health indicators: Under-five mortality reduced 29%, stunting declined from 54% in 2004 to 40% and underweight children declined from 39% to 20% in 2013.

Coverage of several maternal care interventions increased: Antenatal care--care during pregnancy--increased from 16% to 53%, births assisted by a skilled birth attendant from 14% to 46%, and births in a health facility from 13% to 39%. Childhood vaccinations doubled from 40% to 80% during this time.

The reduction in stunting has a lot to do with the health ministry’s focus on early breastfeeding and convergence of various ministries and aid agencies to achieve the goal, according to Homayoun Ludin, director of public nutrition, Ministry of Public Health.

Ludin, 40, was in New Delhi recently for a conference on “Critical Public Health Consequences of the Double Burden of Malnutrition and the Changing Food Environment in South and South-East Asia.” Excerpts from the interview:

When did Afghanistan start the campaign to reduce stunting?

It started in 2002, and we established the public nutrition department under the ministry of public health. For a few years, there was no clear understanding of how to achieve the targets. Then we organised one of the nutrition conferences in Kabul--South Asia Breastfeeding Forum in 2006.

Our minister and deputy minister and those involved in nutrition were mobilised on how to achieve specific actions, especially those which were well-studied like breast feeding, child feeding, complementary feeding and maternal feeding and initiatives like baby-friendly and mother-friendly 'huspatal' [hospital].

Those actions discussed in 2006 started a new movement. We then developed a declaration and started working on that.

This year, our President expressed his interest in reducing child stunting. We have looked at two concepts--reduction of stunting and wasting through poverty reduction and on nutrition in the first 1,000 days of life.

Our first lady also gave a speech on the importance of breastfeeding to national channels showing commitment.

How did you get ministries to converge on the topic of nutrition?

When we did not achieve our goals as we wanted or expected to achieve, we decided this is not just a health issue, and we need to involve other ministries as well. We developed another agenda--food security and nutrition--which is now shared with the general director of the council of ministries, which is the coordinating body of all ministries.

They have a council of ministries and got 17 relevant ministries involved under ‘Afghanistan Food Security and Nutrition’ Agenda.

After the chief executive officer (CEO) of our government released the names for all these ministries, we had a big gathering in 2017. During the day, ministries were called on to develop their plan. Each month, they meet and prepare a plan. We have another meeting called the executive committee meeting and a high level steering meeting in six months where all ministers of the 17 ministries under the leadership of the CEO review the action points of each executive committee for the next six months.

Each ministry has specific terms of reference under nutrition and we have a specific advocacy meeting for each ministry. For example, ministry of rural rehabilitation and ministry of water and sanitation all have a part to play in nutrition. The ministry of education has integrated nutrition topics into the curriculum. The ministry of higher education has established nutrition departments in universities.

As most people follow religious leaders, we have close coordination with the ministry of religious affairs, which work with religious leaders on the importance of  nutrition taking references mentioned in Koran. Now they [religious leaders] speak about nutrition in their speeches during different occasions. It shows the coordination and multi-sectoral approach.

When did you notice improvements in stunting?

We had the first national nutritional survey in 2004, and the second one after 10 years in 2013.

In 2004, the stunting rate was 54%; after ten years, in 2013, it was 40%; the same thing in exclusive breastfeeding: It was 30%, and it is now at 58.4%. So, breastfeeding plays a role in reducing stunting.

Increasing the food security situation as well as sanitation and water are linked with the  reduction of stunting.

So, nutrition is not something to achieve in one year or six months. It takes effort, it’s a long process. Therefore, we conduct the survey after ten years or seven years.

We are conducting another survey, which is a household-level health survey, next year  where we will see stunting or wasting and exclusive breastfeeding. We have four indicators, and will get the results of the survey by the end of 2018.

Why did the ministry focus on breastfeeding?

As breastfeeding is fundamental for health and nutrition, whenever a mother is planning to have a baby, we train mothers about the importance of their [own] health. Religious leaders back the members in their community to support the efforts of mothers to have healthy babies.

Prophet Mohammed in Koran says that a strong Muslim is better than a weak Muslim. So, we say “if we support mothers, strong baby will come to the world”.

First, we support women during the nine months of pregnancy, and we expect well-nourished baby to be around 3.5 kg during pregnancy. After two years, we expect appropriate height and weight… we have kept 86 cm height as our target after the completion of two years.

Breastfeeding is very important for the baby to be well nourished, and it is equally important for mothers to prevent breast cancer and ovarian cancer. We are supporting maternal nutrition during six months of exclusive breastfeeding when there is no chance of treating babies for anaemia.

We are supporting mothers to have nutritious food, and to be supported by family and religious leaders to eat appropriate food.

Is it difficult to talk about breastfeeding in Afghan society? Do women accept you, as a male, talking to them about breastfeeding?

In our society, whenever a man is talking, they [people], and even religious leaders, accept it. Just a few weeks back, I made a presentation to 200 religious leaders, including representatives from the ministry of religious affairs. I spoke at length about six verses of Koran [that support breastfeeding], and they accepted it.

When men come for Friday religious gatherings, they [religious leaders] convey this to them for their wives because it is difficult to speak to women since they don’t come out of the house or visit health facilities even when there are problems.

It is not direct to the women, directly to the women, but to their husbands or religious leaders. In case there are [health] problems, there are female nutritional counsellors at every facility.

What were your observations after visiting a few anganwadis (daycare centres) in India. What are the gaps that you noticed?

The important thing is creating the demand, and the second is supply. If we don’t have supply, then creating demand is not solving the problem.

If we are monitoring growth or weighing a child or measuring the length of the baby, we need to inform mothers that the baby’s height should be 86 cm after six months. If your baby is less than 86 cm after six months, your baby is malnourished.

When the mother asks what she can do, this is the time for counselling, to ask if they still breastfeed the baby and can I (health worker) see or observe.

They (health workers) observe if there is attachment or position problem. If there is not enough or appropriate family support, we support the mother in front of the family so that change can happen.

There is going to be a nutritional counsellor in every health centre in Afghanistan. The hiring for 18 provinces [of 34] is almost done.

What is zero budget and how do you work despite financial limitations?

We have limited financial resources in our country. So, we have used the available resource, which is human resource.

We have 2,000 health facilities and 100 hospitals. To train our staff for each hospital, we need $8,000-10,000 for one batch. If you multiply $10,000 by 100 hospitals, you can see that it is expensive.

Therefore, we train two trainers for each hospital and ask them to train their own staff--in three days, one day or two hours each day for a week during lunch break. This is what we call zero budget.

What is the baby-friendly hospital initiative?

It is mainly in two parts: Whenever a baby is born in the hospital, we will tell the mother to start early initiation of breastfeeding within one hour since support is available. A midwife or nurse will support the mother, and if there are issues like attachment or position issues, they can help them.

Also, no promotion of any kind of breast milk substitute is allowed in our hospitals. No advertisement, no free gifts, brochures or posters are allowed.

We counsel the mothers about early initiation of breastfeeding and each mother coming to the hospital is made aware about the importance of breastfeeding.

Till now, 80 hospitals have been certified as baby-friendly hospitals.

How did you work with different aid agencies that have their own focus areas? How did you collaborate with them?

We work with both foreign and local agencies. While some of them have already received funds, some are looking for funds and developing proposals.

When we draft the national annual plan, we ask everyone to send us their plans and activities. We invite them for a meeting and discuss each point.

For example, in a community, if there are six organisations with their own concept of community-based nutrition, we integrate all of them and bring them under one umbrella and prepare one package and implement it.

Each has a part to play in the plan--water and sanitation, family planning, nutrition--which they show to their donors. The government is facilitating, coordinating and leading the process.

We are not creating problems for agencies but giving them priorities.

(Yadavar is a principal correspondent with IndiaSpend.)

We welcome feedback. Please write to respond@health-check.in. We reserve the right to edit responses for language and grammar.