The BASICS of Child Survival in Afghanistan

[Girls at Enjil Comprehensive Health Center, Herat Province. Photo by Julie O'Brien.]Girls at Enjil Comprehensive Health Center, Herat Province. Photo by Julie O'Brien.Building on a strong history of health-system strengthening in Afghanistan, MSH is working with its partners to cut by half the high number of child deaths over the next four years. At the end of Taliban rule, Afghanistan registered one of the worst child health statistics in the world: one child in four died before reaching age five. Although progress has been made—the under-five child mortality rate has dropped by 25 percent since 2003—today only Sierra Leone has a higher rate.

The Afghanistan Mission of the US Agency for International Development enlisted the MSH-managed Basic Support for Institutionalizing Child Survival (BASICS) Project in late 2007 to strengthen the child health component of the national health care system. Among the project’s accomplishments to date are the introduction of community-based instruction in essential neonatal care and growth monitoring; the addition of integrated management of childhood illness (IMCI) training to the community health worker (CHW) curriculum; and the identification of necessary improvements at hospitals, including emergency triage.

MSH had been at work in Afghanistan well before 2007, however. In 2003, MSH began a concentrated effort to improve the health of women and children in Afghanistan through the Rural Expansion of Afghanistan’s Community-based Healthcare (REACH) Program, which brought health clinics and CHWs to rural areas in 14 provinces. From 2003 to 2006, through REACH, more than two-thirds of the population gained access to basic health services and the under-five Counseling card for mothers in Afghanistan.mortality rate dropped from 257 to 192 per 1,000 live births. 

Despite the gains, these numbers are still nowhere near those of developed countries, and they will not improve unless Afghanistan is able to curtail several underlying problems, one of which is chronic malnutrition—about 40 percent of children under five are underweight and 50 percent are stunted. 

In early 2008, the BASICS Project evaluated gaps in child health care at all levels of the Afghan system and began interventions focused on integration of services and more effective behavior change communication. During its nationwide evaluation, BASICS uncovered a rudimentary health services package that focused on high-mortality conditions in children but did not provide operational guidance for its community-based programs. To be effective, BASICS evaluators believed, the package needed a focused child survival agenda, including protocCounseling card for mothers in Afghanistan.ols for IMCI and nutrition interventions at all levels. 

At the facility level, IMCI protocols were outdated, sometimes lacking fundamental treatments, such as zinc for diarrhea. Training of health care providers was highly centralized, limiting the number of people who could be trained in the latest interventions. Hospitals had no link with IMCI and little or no triage of urgent cases, gaps that led to a disproportionate number of deaths of children. 

At the community level, IMCI protocols were inadequate as well: CHWs focused only on screening and treating malnutrition, instead of preventing it, and were not adequately trained in essential newborn care. And although CHWs generally demonstrated good technical skills, they needed improved counseling skills and better supervision. 

In collaboration with the Afghan government in six provincial hospitals and community demonstration sites in five provinces, the BASICS Project is working to close these gaps. The demonstration projects, the results of which will feed into national programming, focus on community-based case management of disease, essential newborn care, and growth promotion through mobilization of family health action groups. To facilitate this work, BASICS has developed an innovative approach to disseminating information that people can absorb and translate into action. Because more than three-quarters of Afghan women cannot read, BASICS is using illustrated health practice charts and counseling charts like the one above. 

In addition to working with Afghan communities, hospitals, and the government, BASICS works with several other USAID-supported programs in the country and has built partnerships with UNICEF, the World Health Organization, the Global Fund to Fight AIDS, Tuberculosis and Malaria, and other international donors to coordinate efforts. MSH’s work in Afghanistan is based on the experiential understanding that collaborative, integrated programming will result in the greatest improvement in health outcomes.