October 19, 2015

Countdown to 2015: A future of hope for Afghanistan

Written by Nadia Akseer, Biostatistician, SickKids Centre for Global Child Health

A milestone in tracking and accountability of women’s and children’s health, the Countdown to 2015 initiative celebrates its successes and launches its final report this October at the Global Maternal and Newborn Health Conference in Mexico City. Since its first report launched in 2008, Countdown to 2015 has worked to track interventions coverage, equity gaps, health systems, policies, and financials in 75 of the most high burden countries globally in an effort to reduce preventable maternal, newborn and child mortality. Accountability reports and in-depth country profiles have been used to call on governments to be accountable, to identify knowledge gaps and propose new actions to reach MDG 4 and MDG 5.

The commissioning of provocative country case studies in complex and unstable high burden geographies such as Afghanistan epitomizes Countdown’s commitment to improving health of vulnerable women and children in all corners of the world.

Afghanistan is a war-torn, impoverished nation in South-Central Asia of approximately 30 million with some of the worst health and mortality indicators seen globally. Following the 2001 US-invasion of Afghanistan and the fall of the Taliban government, this fragile nation experienced a tumultuous period of democracy overshadowed by festering conflict, widespread insurgency and inflow of development assistance. However, little systematic evidence had been tracked on health gains for the most vulnerable populations (women and children) over that time. Recognizing this global data gap and the urgent need for enumerating gains for accountability and advocacy, Countdown to 2015 commissioned an in-depth systematic study of reproductive, maternal, newborn, and child health (RMNCH) in Afghanistan, complete with assessment of contextual determinants of improvements made in the country. Despite many challenges and 3 years of gestation, the effort which brought together dedicated country experts, funding stakeholders, and members ofthe Countdown family, research community, UN agencies, and government of Afghanistan, is coming to a successful close this 2015.

As a native of Afghanistan raised in Canada, I felt extremely privileged when approached by principal investigator Dr. Zulfiqar Bhutta to engage in the initiative almost 2 years ago. A young statistician and doctoral candidate at the University of Toronto, I took this as a great opportunity to learn more about my homeland and to hone my research and statistical skills. However, I was not prepared for what came in the following years: a sudden realization of how little I knew of the country I’ve long-called homeland; that the nation and provinces where my extended family continue to reside are comparable in health outcomes with some of the poorest nations globally; the Afghan systems are complex and fragile, and trying to understand them would be a continuous steep learning curve; politics are a dirty game and Afghanistan has been long facing its adverse implications; and finally and with bright hope, that Afghanistan is full of passionate and extremely talented resident Afghan professionals who will leave one in awe of their resilience and persistent dedication to improving their country.

With this backdrop, I am proud to highlight some of the key results of our Afghanistan case study. Over a short time period from 2000 to 2013, Afghanistan remarkably managed to reduce maternal mortality rates by 62%- thereby attaining MDG4 target! Not as successful however are the gains in reducing preventable under-5 deaths which only declined by about 29%, and newborn death rates that showed parallel reductions; this implies much work to be done for children as we shift into the sustainable development goal (SDG) era. Pneumonia and diarrhea continue to be the leading causes of under- 5 deaths in country; these infectious diseases are preventable with simple, cost-effective interventions.

Malnutrition has been a long standing problem in Afghanistan. In in the early 2000s, it had been estimated that 25 times more Afghans died every year from undernutrition and poverty than from violence, more than 50% of Afghan children are chronically malnourished, and about one in five will not reach their 5th birthday due to food shortages or common diseases. From 2004 to 2013, the country has managed to decrease the prevalence of chronic undernutrition from 60% to 40% among children under age-5- about 30% reduction in only a decade! There have also been dramatic improvements in the scaling up essential interventions across the continuum of care which tend to women, the newborn, and children in Afghanistan. As an example, the rates of delivering in a health facility, of women seeking antenatal care services, and of having a skilled attendant at birth, have more than tripled from baseline 2003 levels. Administration of childhood immunizations are improving and steadily reaching universal coverage at the national level. Despite these gains, inequities across subnational populations- between the richest and poorest, for those living in isolated and inaccessible areas, between boys and girls- remain pervasive in Afghanistan, and must be tackled to further accelerate progress.

Albeit these promising achievements, Afghanistan is an epic example of a delicate country at risk of regressing in RMNCH and survival gains as various competing and debilitating factors continue to prevail throughout the country. Though classified as “post-conflict” since 2001, Afghanistan today is the most volatile it has been in its recent history. More than 60,000 civilians have died due to battle-related causes since 2005- the majority have been women and children. The effects of over 40 years of war, instability and conflict will gravely manifest itself, and continue to complicate the future of conflict-afflicted men, women and most importantly, children, of Afghanistan. The children of Afghanistan need dire support and continued assistance from the global community to prevent a vicious cycle of ill health, radicalisation and poverty. Today I have had the luxury of working with Countdown to narrate the Afghan story, but it is my dream that one day the children of Afghanistan will be able to rise up despite their predisposing unfortunate plight, and tell their success story; a story that underscores their emergence from darkness into a future of hope and victory in Afghanistan.

We are grateful to Countdown for their support of work in difficult, conflict-afflicted geographies like Afghanistan, and hope for continued partnership as we moved forward in tracking Afghanistan’s, and other similar countries’, successes and challenges in the SDG era. In line with the next phase of Countdown (TBD post-2015), which includes commitments to cross-cutting analyses across fragile, high burden countries, our group at the Centre for Global Child Health at The Hospital for Sick Children (SickKids) is leading an effort with Countdown to explore RMNCH, survival and an assessment of conflict in the broader Islamic World. This multi-country assessment will examine trends and determinants in more than 50 Muslim countries globally. Results from this analyses are forthcoming.