Afghanistan: sustaining health care delivery

It wasn’t until the start of the 21st century that Afghanistan had a government-led public health delivery system for its citizens, enshrined in its Constitution as a basic right. Najibullah Safi and Palwasha Anwari, both of whom have work experience in the sector, make a case for the health delivery apparatus — dependent as it is on foreign aid — to continue despite the fall of civilian government and the Taliban takeover of power in August 2021

Contracting of primary health care services in Pakistan: is up-scaling a pragmatic thinking

Quite often, public health care systems in developing countries are struggling because of incompetence and a lack of provider responsiveness to the needs of consumers. On the contrary, the private sector dominates the system of health provision. In recent years, contracting has been experimented as an approach to ensure delivery of comprehensive public health services in an efficient, effective, superior and fair manner and has generally thrived well. The state\u27s healthcare system in Pakistan has suffered a lot, owing to structural fragmentation, resource scarcity, inefficiency and lack of functional specificity, gender insensitivity and inaccessibility. However, partnering with the private sector has shown some exceptional accomplishments. Though challenging but structural reforms, involving private health sector have become indispensable. The overall experience shows that up-scaling of such initiatives in the country would require lot of cautions to be taken by the government

Towards malaria risk prediction in Afghanistan using remote sensing

<p>Abstract</p> <p>Background</p> <p>Malaria is a significant public health concern in Afghanistan. Currently, approximately 60% of the population, or nearly 14 million people, live in a malaria-endemic area. Afghanistan's diverse landscape and terrain contributes to the heterogeneous malaria prevalence across the country. Understanding the role of environmental variables on malaria transmission can further the effort for malaria control programme.</p> <p>Methods</p> <p>Provincial malaria epidemiological data (2004-2007) collected by the health posts in 23 provinces were used in conjunction with space-borne observations from NASA satellites. Specifically, the environmental variables, including precipitation, temperature and vegetation index measured by the Tropical Rainfall Measuring Mission and the Moderate Resolution Imaging Spectoradiometer, were used. Regression techniques were employed to model malaria cases as a function of environmental predictors. The resulting model was used for predicting malaria risks in Afghanistan. The entire time series except the last 6 months is used for training, and the last 6-month data is used for prediction and validation.</p> <p>Results</p> <p>Vegetation index, in general, is the strongest predictor, reflecting the fact that irrigation is the main factor that promotes malaria transmission in Afghanistan. Surface temperature is the second strongest predictor. Precipitation is not shown as a significant predictor, as it may not directly lead to higher larval population. Autoregressiveness of the malaria epidemiological data is apparent from the analysis. The malaria time series are modelled well, with provincial average R²of 0.845. Although the R²for prediction has larger variation, the total 6-month cases prediction is only 8.9% higher than the actual cases.</p> <p>Conclusions</p> <p>The provincial monthly malaria cases can be modelled and predicted using satellite-measured environmental parameters with reasonable accuracy. The Third Strategic Approach of the WHO EMRO Malaria Control and Elimination Plan is aimed to develop a cost-effective surveillance system that includes forecasting, early warning and detection. The predictive and early warning capabilities shown in this paper support this strategy.</p

Potential impact and cost-effectiveness of rotavirus vaccination in Afghanistan.

INTRODUCTION: Despite progress made in child survival in the past 20 years, 5.9 million children under five years died in 2015, with 9% of these deaths due to diarrhea. Rotavirus is responsible for more than a third of diarrhea deaths. In 2013, rotavirus was estimated to cause 215,000 deaths among children under five years, including 89,000 in Asia. As of April 2017, 92 countries worldwide have introduced rotavirus vaccination in their national immunization program. Afghanistan has applied for Gavi support to introduce rotavirus vaccination nationally. This study estimates the potential impact and cost-effectiveness of a national rotavirus immunization program in Afghanistan. METHODS: This study examined the use of Rotarix® (RV1) administered using a two-dose schedule at 6 and 10 weeks of age. We used the ProVac Initiative's UNIVAC model (version 1.2.09) to evaluate the impact and cost-effectiveness of a rotavirus vaccine program compared with no vaccine over ten birth cohorts from 2017 to 2026 with a 3% annual discount rate. All monetary units are adjusted to 2017 US$. RESULTS: Rotavirus vaccination in Afghanistan has the potential to avert more than one million cases; 660,000 outpatient visits; approximately 50,000 hospital admissions; 650,000 DALYs; and 12,000 deaths, over 10 years. Not accounting for any Gavi subsidy, rotavirus vaccination can avert DALYs at US$82/DALY from the government perspective and US$80/DALY from the societal perspective. With Gavi support, DALYs can be averted at US$29/DALY and US$31/DALY from the societal and government perspective, respectively. The average yearly cost of a rotavirus vaccination program would represent 2.8% of the total immunization budget expected in 2017 and 0.1% of total health expenditure. CONCLUSION: The introduction of rotavirus vaccination would be highly cost-effective in Afghanistan, and even more so with a Gavi subsidy

Potential health impact and cost-effectiveness of bivalent human papillomavirus (HPV) vaccination in Afghanistan.

INTRODUCTION: Human papillomavirus (HPV) vaccination has not been introduced in many countries in South-Central Asia, including Afghanistan, despite the sub-region having the highest incidence rate of cervical cancer in Asia. This study estimates the potential health impact and cost-effectiveness of HPV vaccination in Afghanistan to inform national decision-making. METHOD: An Excel-based static cohort model was used to estimate the lifetime costs and health outcomes of vaccinating a single cohort of 9-year-old girls in the year 2018 with the bivalent HPV vaccine, compared to no vaccination. We also explored a scenario with a catch-up campaign for girls aged 10-14 years. Input parameters were based on local sources, published literature, or assumptions when no data was available. The primary outcome measure was the discounted cost per disability-adjusted life-year (DALY) averted, evaluated from both government and societal perspectives. RESULTS: Vaccinating a single cohort of 9-year-old girls against HPV in Afghanistan could avert 1718 cervical cancer cases, 125 hospitalizations, and 1612 deaths over the lifetime of the cohort. The incremental cost-effectiveness ratio was US$426 per DALY averted from the government perspective and US$400 per DALY averted from the societal perspective. The estimated annual cost of the HPV vaccination program (US$3,343,311) represents approximately 3.53$586) from both the government and societal perspective with additional health benefits generated by a catch-up campaign, depending on the government's willingness to pay for the projected health outcomes

Post-marketing surveillance of intussusception after Rotarix administration in Afghanistan, 2018-2022.

BACKGROUND: In January 2018, Afghanistan introduced the monovalent oral rotavirus vaccine (Rotarix) nationwide, administered as a 2-dose series at six and ten weeks of age. We describe characteristics of intussusception cases and assess potential intussusception risk associated with Rotarix vaccination in Afghan infants. METHODS: Multi-center prospective active hospital-based surveillance for intussusception was conducted from May 2018 to March 2022 in four sentinel sites in Afghanistan. We applied the Brighton Level 1 criteria for intussusception and verified vaccination status by reviewing vaccine cards. We used the self-controlled case series (SCCS) methodology to compare intussusception incidence in the 1 to 21 days after each dose of Rotarix vaccination against non-risk periods. RESULTS: A total of 468 intussusception cases were identified in infants under 12 months, with 264 cases aged between 28 and 245 days having confirmed vaccination status contributing to the SCCS analysis. Most case-patients (98 %) required surgery for treatment, and over half (59 %) of those who underwent surgery required intestinal resection. Nineteen (7 %) case-patients died. Eighty-six percent of case-patients received the first dose of Rotarix, and 69 % received the second dose before intussusception symptom onset. There was no increased risk of intussusception in the 1-7 days (relative incidence: 0.9, 95 % CI: 0.1, 7.5), 8-21 days (1.3, 95 % CI: 0.4, 4.2), or 1-21 days (1.1, 95 % CI: 0.4, 3.4) following receipt of the first dose or in the 1-7 days (0.2, 95 % CI: 0.3, 1.8), 8-21 days (0.7, 95 % CI: 0.3, 1.5), or 1-21 days (0.6, 95 % CI: 0.3, 1.2) following the second dose. CONCLUSION: Rotarix vaccination was not associated with an increased intussusception risk, supporting its continued use in Afghanistan's immunization program. However, there was a high level of death and resection due to intussusception among Afghan infants

The need to sustain funding for Afghanistan health system to prevent excess morbidity and mortality

BACKGROUND: The Afghanistan Reconstruction Trust Fund, managed by the World Bank through a contracted-out instrument called Sehatmandi, financed health service delivery in Afghanistan, with substantial achievements in infant, child and maternal health. After the collapse of the Afghan Government on 15 August 2021, the health system has been on the brink of collapse. AIMS: We assessed the use of basic health services and estimated excess mortality resulting from the interruption to healthcare funding. METHODS: We conducted a cross-sectional study that compared health services utilization from June to September for 3 consecutive years, 2019, 2020 and 2021, using 11 output indicators reported by the health management and information system. We used the Lives Saved Tool, a linear mathematical model with input data from the Afghanistan Demographic Health Survey 2015, to calculate the additional maternal, neonatal and child mortality at 25%, 50%, 75% and 95% reduction in health coverage. RESULTS: During August and September 2021, after the announced ban on financing, health service utilization decreased to a range of 7-59%. Family planning, major surgeries and postnatal care showed the greatest decreases. Uptake of child immunization showed one-third decrease. Sehatmandi provides around 75% of primary and secondary health services: pausing funds to this programme will result in additional 2862 maternal deaths, 15 741 neonatal deaths, 30 519 child deaths, and 4057 stillbirths. CONCLUSION: Sustaining the current level of health services delivery is crucial to avoid excess, preventable morbidity and mortality in Afghanistan. Contexte : Le Fonds d'affectation spéciale pour la reconstruction de l'Afghanistan, géré par la Banque mondiale au moyen d'un programme sous-traité appelé Sehatmandi, a financé la prestation de services de santé en Afghanistan, ce qui a permis d'obtenir des résultats substantiels en matière de santé du nourrisson, de l'enfant et de la mère. Après la chute du Gouvernement afghan le 15 août 2021, le système de santé était sur le point de s'effondrer. Objectifs : Nous avons évalué le recours aux services de santé de base et estimé la surmortalité résultant de l'interruption du financement des soins de santé. Méthodes : Nous avons mené une étude transversale qui a permis de comparer l'utilisation des services de santé entre juin et septembre pendant trois années consécutives, de 2019 à 2021, à l'aide de 11 indicateurs de résultats rapportés par le système de gestion et d'information sanitaires. Nous avons utilisé l'outil des vies sauvées, un modèle mathématique linéaire basé sur les données fournies par l'enquête démographique et sanitaire d'Afghanistan menée en 2015, afin de calculer la mortalité supplémentaire de la mère, de l'enfant et du nourrisson pour une réduction de 25 %, 50 %, 75 % et 95 % de la couverture sanitaire. Résultats : En août et septembre 2021, après l'annonce de l'interdiction des financements, l'utilisation des services de santé a chuté pour atteindre une fourchette de 7 à 59 %. La planification familiale, les interventions chirurgicales majeures et les soins postnatals ont enregistré les baisses les plus importantes. L'utilisation des services de vaccination des enfants a diminué d'un tiers. Le programme Sehatmandi fournit près de 75 % des services de santé primaires et secondaires : l'interruption des fonds alloués à ce programme entraînera 2862 décès maternels, 15 741 décès néonatals, 30 519 décès d'enfants et 4057 mortinaissances supplémentaires. Conclusion : Il est essentiel de maintenir le niveau actuel de prestation des services de santé afin d'éviter une morbidité et une mortalité excessives qui peuvent être prévenues en Afghanistan

Lessons from the development process of the Afghanistan integrated package of essential health services

In 2017, in the middle of the armed conflict with the Taliban, the Ministry of Public Health decided that the Afghan health system needed a well-defined priority package of health services taking into account the increasing burden of non-communicable diseases and injuries and benefiting from the latest evidence published by DCP3. This leads to a 2-year process involving data analysis, modelling and national consultations, which produce this Integrated Package of Essential health Services (IPEHS). The IPEHS was finalised just before the takeover by the Taliban and could not be implemented. The Afghanistan experience has highlighted the need to address not only the content of a more comprehensive benefit package, but also its implementation and financing. The IPEHS could be used as a basis to help professionals and the new authorities to define their priorities