Afghanistan

Humanitarian Need

The weak health system of Afghanistan and the unequal access to healthcare has led to a significant increase in health needs among millions of Afghans. Afghanistan's health system faces numerous challenges, including inadequate funding, heavy reliance on foreign aid, a shortage of healthcare professionals, and limited access to quality healthcare, particularly for women and those living in inaccessible areas. The country continues to suffer from ongoing outbreaks of communicable diseases, health impacts of disasters and emergencies, unmet maternal and child health needs, and high rates of malnutrition. These factors substantially contribute to the high mortality and morbidity of Afghans. Additionally, non-communicable diseases are on the rise, accounting for 52 percent of all deaths in the country.¹

The humanitarian crisis and additional shocks further strain the healthcare system's capacity and services. Many health facilities suffer from poor infrastructure, lack of medical supplies and equipment and a shortage of qualified healthcare workers (many have left the country and those who remained are primarily concentrated in urban areas, thus exacerbating the situation). Limited resources and capacity within the public health system - along with hidden costs for private care and medicines - create additional barriers to healthcare access in Afghanistan. Auxiliary costs, including transportation expenses, worsen the challenges of accessing healthcare, particularly in the current socio-economic environment, where people's coping capacities are diminished.

The most prevalent and continuing shock to the health system are disease outbreaks, including Acute Watery Diarrhea (AWD), measles, Crimean Congo Haemorrhagic Fever (CCHF), dengue fever, pertussis, malaria and Acute Respiratory Infections (ARI). COVID-19 cases are still being reported. From January to December 30, 2023, a total of 230,629 cases of COVID-19; 222,230 cases of AWD; 25,856 cases of measles; 1,496 cases of dengue fever; and 1,236 cases of CCHF were reported by 613 sentinel sites.² Additionally, six cases of poliovirus type one were reported during the same period.³

The winter season is expected to contribute to outbreaks of respiratory infections, further compounded by the population’s diminished immune response. In many parts of the country, heavy snowfall during winter months leads to blocked roads, impeding referrals to secondary healthcare facilities and delaying the provision of life-saving medical services and supplies to isolated communities. This situation increases morbidity and mortality caused by respiratory infections, particularly among vulnerable groups such as children under the age of five and the elderly. However, the summer poses different problems, as limited access to safe drinking water and low public awareness may result in a high number of AWD cases.

Maternal and child health needs, coupled with malnutrition, remain significant contributors to mortality and morbidity in Afghanistan. The country has one of the highest maternal mortality rates globally, with 620 deaths per 100,000 live births.⁴ Additionally, under-5 mortality stands at 55 deaths per 1,000 live births.⁵ Restrictions on women's movement persist, hindering their access to critical health services, particularly reproductive healthcare and limiting women’s ability to access life-saving health services.

Trauma cases remain high due to widespread contamination of explosive ordnances, sporadic explosions, road traffic accidents and natural calamities such as earthquakes. From January to November 2023, a total of 402,909 trauma cases were treated.⁶ The population of Afghanistan faces high exposure to traumatic events and psychosocial problems. Nearly half of Afghans experience psychological distress; one in five is impaired in their daily functioning due to mental health issues.⁷

In 2024, the Health Cluster anticipates health vulnerabilities associated with the influx of returnees from neighboring countries and the potential occurrence of earthquakes and floods, which could result in increased displacement. The influx of returnees and internal displacement, which in turn lead to population movement and increased occurrence of illnesses, place additional strain on existing health issues.

Recently, in the 3rd Quarter of the Community Voices bulletin, affected individuals have identified healthcare as their second highest priority. They emphasize the need for additional health infrastructure in remote areas, an increase in female staff, greater health education and awareness, and the provision of Mental Health and Psychosocial Support (MHPSS) services to address psychosocial issues. Furthermore, they have highlighted that financial constraints and lack of access prevent them from seeking treatment for various ailments.⁸

Response Strategy

The Health Cluster aims to protect people’s health by ensuring the delivery of quality healthcare, preventing the transmission of communicable diseases, and managing outbreaks and other incidents that threaten public health. The strategic priority actions include maintaining and increasing access to lifesaving and life-sustaining health services and information. This is achieved by supporting the delivery of primary and secondary healthcare services, including maternal and reproductive health, MHPSS, trauma care, care for non-communicable diseases as well as the procurement and provision of medicines, medical supplies and equipment, and vaccines. Additionally, the cluster focuses on strengthening disease outbreak prevention, preparedness, and response; supporting disability and physical rehabilitation services; and building the capacity of healthcare workers. Community-based interventions and community engagement is also strengthened to ensure that healthcare delivery remains responsive to affected people’s voices, priorities, and concerns.

The delivery of healthcare services is supported through static and rationalized mobile health facilities. While the overall priorities remain the same in urban and rural settings, support to primary healthcare services is prioritized in rural and underserved areas under humanitarian action.

To ensure the safe access of women and girls, health partners prioritize the recruitment of female staff in both urban and rural settings. Furthermore, health services are delivered in locations that ensure safe and easy access for vulnerable groups, including women, adolescents, children, older adults, and persons with disabilities. The aim is to remove barriers that may prevent these groups from seeking and receiving healthcare.

The Health Cluster's key response priorities include:

• Improve access to primary and secondary healthcare services through static and rationalized mobile health teams. Special attention will be given to underserved areas and vulnerable populations that lack access to essential healthcare services.
• Prevent, prepare, detect and respond to epidemic-prone diseases through strengthening infectious disease outbreak preparedness and response mechanisms. This includes supporting activities related to Risk Communication and Community Engagement (RCCE) to raise awareness and promote preventive measures.
• Provide comprehensive reproductive health services, including the Minimum Initial Service Package (MISP), emergency obstetric and newborn care, healthcare for survivors of violence, and tailored services for adolescents.
• Increase the capacity and coverage of MHPSS services, including training healthcare workers in mental health prevention and treatment.
• Support trauma care services with a focus on conflict-induced trauma cases and emergency referral systems.
• Prevention, screening, diagnosis, and initial treatment of non-communicable diseases.
• Support disability and physical rehabilitation services.
• Provide in-service training to healthcare workers, including healthcare response to survivors of violence and identification and reporting of sexual exploitation and abuse.
• Support management of severe acute malnutrition with complications in children under the age of five.
• Ensure the supply of quality medicines, medical supplies and equipment.
• Maintain and enhance coordination and collaboration with other clusters, including Nutrition, WASH, Food Security and Agriculture, Education, Protection, Emergency Shelter and Non-Food Items.

The Health Cluster has not extensively utilized cash programming in its operations. However, some partners provided cash to support referrals, and some supported Maternal and Child Cash Transfer (MCCT) programs. The implementation of cash programming has been hindered by the health partners’ limited capacity in this area and the Ministry of Public Health's (MoPH's) directive prohibiting the provision of cash to project beneficiaries. These factors act as constraints to the wider adoption of cash programming within the Health Cluster's activities.

Targeting and Prioritization

The Health Cluster considered accessibility, availability, health service coverage, health status, epidemic disease incidence, and vulnerability-related indicators to assess severity at the district and provincial levels. In 13 provinces, there has been a slight increase in the severity of needs, while in 18 provinces, a slight decrease has been observed. In severity 4 (extreme/critical) districts, 95 percent of the people in need are targeted, while targets in severity 3 (severe) districts have been reduced to 65 percent to prioritize the most critical areas.

Geographic prioritization in urban and rural settings will remain the same. There will be a particular emphasis on supporting primary healthcare services and referrals in rural or hard-to-reach underserved areas. The focus will continue to be on vulnerable groups, including women, children under the age of five, the elderly, people with disabilities, Internally Displaced Populations (IDPs), and returnees. Additionally, in 2024, the focus will solely be on conflict-induced trauma cases.

Based on the funding availability, the Health Cluster will reprioritize interventions and targets as follows:

• If Health Cluster receives 75 percent of the required funding, there will be no major changes to the prioritized health activities. However, approximately 3.2 million people will be unable to access essential health assistance.
• If 50 percent of the required funding is received, the Health Cluster will need to re-prioritize activities, geographic focus, and target beneficiaries. The primary focus will be on primary health care, disease outbreak response, and trauma care. Unfortunately, around 4.5 million people will miss life-saving health assistance.
• If only 25 percent of the required funding is received, the Health Cluster will primarily concentrate on life-saving activities within primary health care. This includes outpatient consultations, management of childhood illnesses, immunization, and reproductive and maternal care in rural and underserved areas. Due to reduced funding, approximately seven million people will be unable to access essential life-saving health assistance.

The decrease in funding will result in a reduced number of people reached and a decrease in the scale of support, including the number of geographical locations covered. Consequently, there will be an increase in morbidity and mortality, particularly among pregnant and lactating women, children under the age of five, people with disabilities, elderly individuals, IDPs, returnees, and those residing in remote and underserved areas. Further, low-income families will be more vulnerable to catastrophic health expenses, perpetuating the cycle of poverty.

Quality and Inclusive Programming

To ensure accountable and gender-responsive humanitarian health assistance, the Health Cluster in collaboration with relevant technical working groups will provide support to health partners in applying minimum standards for AAP, PSEA, Gender, and Disability Inclusion. These standards will guide the design, assessment, implementation, and monitoring and evaluation of the humanitarian health response, aiming to promote high-quality programming that is inclusive, gender-sensitive, and accountable.

Additionally, to ensure the equitable and meaningful participation of women and other vulnerable groups in the humanitarian response, the Health Cluster recommends the following actions:

• Promote an environment that prohibits any form of violence, including sexual exploitation and abuse, by ensuring that Health Cluster partners are adequately supported to comply with prevention and response standards for sexual exploitation and abuse in emergency settings.
• Ensure that women have meaningful, equitable, and safe opportunities to access and benefit from humanitarian assistance, services, communication, information, and assessments.
• Raise awareness among women, girls, and other vulnerable groups about their rights to health-related assistance during emergencies, including how to safely report incidents.
• Facilitate the active participation of community members and project beneficiaries, including women and vulnerable groups, in the community engagement process. This platform can be utilized to discuss the challenges faced by women and vulnerable groups and identify potential solutions to address them.
• Provide training for frontline healthcare workers on reporting and referring cases of sexual exploitation and abuse, following the standard operating procedures for recording such cases in health centers.
• Prioritize the recruitment and retention of female staff members to promote safe access to services for women and girls, recognizing the importance of having a diverse and gender-sensitive workforce.
• Provide necessary support, such as covering Mahram costs, for female staff members to ensure their full participation and engagement in the humanitarian response.
• Ensure that all collected data is disaggregated by sex and age at the activity/indicator level. This approach guarantees equitable inclusion of women, girls, men, and boys in project benefits and ensures their specific needs are adequately addressed.

These actions aim to foster inclusivity, address gender-based disparities, and promote the active involvement of women and other vulnerable groups in shaping and benefiting from the humanitarian response.

The Health Cluster is committed to promoting the inclusion of elderly individuals and people with disabilities in its programs through the adoption of minimum standards for the inclusion of individuals with age and disability in humanitarian action. It is crucial to ensure that people with disabilities and elderly individuals receive gender-responsive humanitarian assistance that addresses their specific vulnerabilities, needs, and capacities.

To meet the needs of people with disabilities, the following activities are suggested:

• Place emphasis on prioritizing people with disabilities in the provision of healthcare and rehabilitation services.
• Remove infrastructural barriers and incorporate disability-friendly design standards in healthcare construction.
• Develop information and awareness products designed for people with disabilities.
• Include rehabilitation services as part of essential healthcare services and establish clear referral pathways.
• Incorporate disability and persons with disabilities in healthcare surveillance efforts and advocate for the disaggregation of disability data.
• Ensure that all data collected from health projects is disaggregated by disability, sex, age, and geographical location.
• Promote the inclusion of assistive devices and related procurement systems within essential healthcare services.

By implementing these activities, the Health Cluster aims to ensure that elderly individuals and people with disabilities are included and supported in its programs. It seeks to provide equitable access to healthcare services that address their specific needs and promote their well-being.

Links to basic services and development programmes

Over the years, humanitarian support has played a complementary role to the Health Emergency Response (HER) project, which serves as the fundamental public health program in Afghanistan. Out of more than 4,000 health facilities in the country, over 2,300 received support from the HER project to provide primary and secondary healthcare services nationwide.

As humanitarian assistance and services utilize existing health personnel and facilities, there are direct links between development and humanitarian efforts in the health sector. Disruptions in the delivery of basic health services through the HER project can have adverse effects on the humanitarian response, leading to an increase in humanitarian caseloads. Similarly, failures in the humanitarian response during epidemics or natural disasters, such as earthquakes or floods, can strain the health system supported by the HER project. The HER project must maintain and strengthen support for health facilities, expand service delivery, and ensure service quality to avoid compromising healthcare delivery and increasing the need for humanitarian assistance.

On the other hand, the humanitarian response can explore alternative approaches to service delivery, such as utilizing mobile teams to reach unserved areas or responding to natural disasters and epidemics. Any shortcomings in either system's response would result in an increased demand for healthcare services, leading to higher costs for the humanitarian response. Currently, the Health Cluster partners lack sufficient capacity to handle an increase in needs and would require additional resources.

To reduce humanitarian needs, the 2024 HRP will prioritize trauma management, particularly for cases resulting from conflict-induced trauma. Non-conflict-induced trauma cases will be supported through basic services. Additionally, the majority of the 613 sentinel sites that provide data on communicable disease outbreaks are in the HER project supported health facilities.

To support the implementation of the New Aid Architecture for Afghanistan, the Strategic Thematic Working Groups (STWGs) have been established. The STWGs focus on addressing basic human needs aligned with the UN’s Strategic Framework in Afghanistan. The Health Sector Thematic Working Group (H-STWG) specifically aims to enhance coordination between humanitarian and development efforts in the health sector. By fostering collaboration and cooperation among stakeholders, the H-STWG seeks to address programmatic and policy challenges in delivering health assistance in Afghanistan, ultimately improving the effectiveness and impact of health-related interventions.

Response Monitoring

Health Cluster partners actively report every month through ReportHub. The response data provided by the partners is collected and analyzed regularly. In addition to ReportHub, Health Cluster partners support 613 surveillance sentinel sites across 34 provinces. Epidemiological surveillance data is collected and analyzed regularly to plan and monitor the evolving health situation.

The completeness, timeliness, and consistency of the data reported by health partners remain a concern. Delays in reporting lead to delays in data validation, analysis, and the production of information products such as infographics. Some health partners supporting humanitarian health projects do not utilize ReportHub, some do not report regularly through ReportHub, a few report for non-humanitarian projects, and there is some overlap in the reports.

To address these challenges, the Health Cluster will continue proactive engagement with health partners to improve reporting through ReportHub and strengthen partners' information management capacity. Specifically, the Health Cluster will:

• Build the capacity of health partners in data management and visualization, including completeness, consistency, and timely reporting, in coordination with the Global Health Cluster, iMMAP, and other local institutions.
• Enhance the functionality of the Health Cluster Information Management Working Group.
• Emphasize the importance of information sharing.
• Encourage partners to receive training on ReportHub and coordinate with iMMAP's focal person to conduct regular and refresher training on ReportHub.

Additionally, Health Cluster partners will consider periodic assessments (quarterly) of health facilities using HeRAMS tools. This will provide up-to-date information on the availability of health resources and services, identify gaps, and determine intervention priorities. Furthermore, the Health Cluster will maximize the utilization of available information systems such as DHIS2 and WHO's Health Information Hub to identify gaps and determine priority interventions in different geographic locations.

ReportHub also collects information on services for people with disabilities. The Health Cluster has included an indicator, "Number of people with disabilities receiving rehabilitative care," to track the provision of rehabilitative care to individuals with disabilities.

Health services will be gender-sensitive, and frontline healthcare workers will be trained on recognizing signs of abuse and violence, as well as appropriate referral mechanisms.

To mitigate risks related to Prevention and response to Sexual Exploitation and Abuse (PSEA), mandatory training will be implemented for healthcare personnel and partners. An action plan specific to PSEA will be developed to support the implementation, monitoring, and reporting of prevention and response measures to sexual exploitation and abuse in health emergencies. Furthermore, the reinforcement of PSEA codes of conduct for all healthcare providers will emphasize the importance of maintaining a safe and respectful environment. The Health Cluster will collaborate closely with the PSEA and Gender-Based Violence (GBV) network to establish survivor support services, accessible complaints and feedback mechanisms, and secure reporting channels within healthcare settings. These efforts aim to ensure that individuals feel comfortable and supported when reporting incidents of sexual exploitation and abuse. Additionally, internal systems for reporting and investigating cases of sexual exploitation and abuse will be established to facilitate thorough and timely investigations when necessary. To monitor progress, SEA indicators will be included in the Health Cluster monitoring framework, and progress will be evaluated quarterly.

With the support of a dedicated Accountability to Affected Populations (AAP) Technical Specialist, the Cluster will prioritize enhancing the capacity of implementing partners to facilitate affected people's access to information. It will establish reliable, confidential, and accessible mechanisms to capture feedback from affected individuals. The Cluster will actively adjust its programming based on the feedback received and report back to affected people, ensuring a closed feedback loop. To assess inclusion, safety, participation, satisfaction, treatment, and feedback, the Cluster will introduce perception monitoring and partner monitoring indicators. Furthermore, the Health Cluster will maintain collaboration with the AWAAZ - inter-agency feedback mechanism - and the AAP Working Group. This collaboration will aim to address complaints received from affected persons, analyze trends, and effectively listen and respond to the needs of vulnerable groups, such as women, girls, the elderly, and persons with disabilities.

PiN Calculation Methodology

The Health Cluster determined the number of people in need (PIN) in health by following the guidance provided by the Global Health Cluster (GHC) and Severity Guidance. In order to assess the severity of needs more effectively, the cluster relied on various data sources, including WHO surveillance data, Nutrition SMART survey data, IPC analysis, DHIS2, and the WHO Information Hub.

The following indicators were identified to collect data on health services and health status at the district/province level, based on their availability:

• PENTA3 Coverage (<1 year old), obtained from DHIS2 at the district level
• Measles 2 Coverage (<2 years old), obtained from DHIS2 at the district level
• Percentage of births assisted by a skilled attendant/health personnel, obtained from DHIS2 at the district level
• Health workers per 10,000 population, obtained from DHIS2 at the district level
• Ante-Natal Care (ANC) visits, obtained from DHIS2 at the district level
• Incidence rate of most common diseases (AWD, Measles, ARI), obtained from WHO surveillance data at the district level
• Underserved population in white/underserved areas, obtained from the WHO Information Hub at the district level
• Under 5 death rate, obtained from the SMART survey 2022 at the provincial level
• Prevalence of Global Acute Malnutrition (GAM), obtained from the SMART survey 2022 at the provincial level
• IPC Analysis, conducted from May to October 2023 at the provincial level

Thresholds for the above indicators have been established based on standard guidelines such as Sphere, IASC and WHO guidelines. These thresholds were used to assign a severity score ranging from 1 to 5 for each indicator. The overall severity score was then calculated by weighting the severity scores of individual indicators, taking into account their importance and contribution.

The health PIN was calculated at the district level as a percentage of the population, using the overall severity score. The results were then aggregated at the provincial level, distinguishing between urban and rural areas, based on OCHA's population projections.

Once the health PiN calculator was applied, the results were shared with a pre-identified panel of experts known as the Expert Judgement Group. This group consisted of the Health Cluster Coordination Team and the Strategic Advisory Group (SAG) of the Health Cluster, who possess expertise in analysis and extensive local and contextual knowledge of the geographic region covered by the HNO.