However, if we consider the situation ten years ago:
- women were unable to work in most parts of Afghanistan.
- the health system barely functioned in cities, let alone in the countryside - where most Afghans live.
As a result, Afghanistan had some of the worst health indicators in the world - particularly for maternal and child mortality.
The maternal mortality ratio was 1400 deaths per 100.000 live births, which translates into 50 maternal deaths each day, or, for an individual woman, a risk of 1 in 11 for her to die of maternal causes during her life time, one of the highest in the world.
As we known, the causes for this are multiple: we know, for example that only 14% of them had the help of a skilled attendant during birth, but it is not just related to health care. It is also a reflection of the low level of education of women who have a literacy rate of 13%, compared with 43% among men. It is also a reflection of early marriage, with over half of the women married before the age of 18, and we know that pregnancies are more risky for adolescent girls. It is also a reflection of a very low use of contraception, with only 16% of women of reproductive age using modern methods of contraception, and we know that pregnancies that are too close or too numerous carry more risk.
But today, this is changing. The situation is changing slowly. But surely, for the better. Girls are in schools, midwives are being trained, and women are working as teachers and health workers. In fact, a Mortality Survey was carried out recently and preliminary results show that maternal mortality is declining. We expect the results to be released officially next month.
This reflects the high priority given by the Government and its partners to maternal and child health and several years of sustained effort. WHO is one of those partners and our office has been providing support in the field of family planning and community health. Just to give some examples, this has been in the form of:
- training of health personnel in clinical care in reproductive health and in gender and rights issues
- training of trainers for reproductive health in emergencies
- community-based projects to increase the adoption of family
- operations research to facilitate the uptake of certain interventions
(haemoglobin color scale, use of the partograph).
Last September, the Government of Afghanistan renewed its commitment by pledging its support to the Global Strategy for Women's and Children's Health launched by Secretary General Ban Ki-Moon.
- increase public spending on health from $10.92 to at least $15 per capita by 2020.
- increase the proportion of deliveries assisted by a skilled professional from 24% to 75% through strategies such as increasing the number of midwives from 2400 to 4556 and increasing the proportion of women with access to emergency obstetric care to 80%.
- also improve access to health services ‐ strengthening outreach, home visits, mobile health teams, and local health facilities.
- increase the use of contraception from 15% to 60%, the coverage of childhood immunization programs to 95%, and universalize Integrated Management of Childhood Illness.
WHO and its sister UN organizations are committed to supporting this action. Specifically, the group of H4+ which includes WHO, UNFPA, UNICEF, UNAIDS and the World Bank, is working alongside the Government of Afghanistan to implement a joint action plan to reduce maternal and newborn mortality.
- to jointly mobilize funding and technical expertise for multi-sectoral activities for reducing maternal and newborn mortality;
- to strengthen the Government’s capacity to provide quality maternity and newborn care,
- to enhance women’s access to health care by increasing the availability, affordability and acceptability of health care, including outreach in the community, and
- to increase women’s ability to access resources for care through education.
This progress is encouraging but much hard work remains to be done. Afghanistan is a large country with a very scattered population. Getting skilled health workers - particularly female health workers - into every mountain village is a real challenge. Keeping them there can be an even greater one. Providing them with regular supplies of the medicines they need, and even the most basic technologies requires strong health systems - both in terms of quality control, and logistics. Setting up robust mechanisms to pay for all of this will be critical. WHO's policy on Primary Health care, on Human resource for health and for the financing of Universal coverage are particularly relevant if countries must achieve the health and wellbeing of all their citizens.
This highlights the need for long-term engagement - and a willingness to focus on setting up and maintaining systems and infrastructure that last.
For this, we need to pull all forces together with the same vision.