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Country With High Mortality: Afghanistan

The health of individuals and communities relies on a combination of factors. Health, or lack of, depends on circumstances facing people, in addition to environmental factors. Factors such as the social environment, genetic access to health facilities, government policies and intervention, personal behavior, and coping skill play a crucial role in determining the overall population of individuals and the community. In Afghanistan, maternal mortality and infant mortality rates are among the highest in the world (World Health Organization, 2012). Prolonged periods of war have resulted in underdeveloped physical infrastructure such as roads, while the health care sector is also wanting owing to lack of funds to purchase drugs and employ enough health care professionals. This has made a huge contribution to the country’s burden of disease. However, all is not lost, and the government is in partnership with international donors and NGOs to improve healthcare delivery in Afghanistan. The government, through the ministry of Health, has also identified key health priorities that it hopes to achieve in its quest to improve health care delivery, including reducing maternal and child mortality rates.

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Location/Geography

Afghanistan is a land-locked country in Southern Asia. The country borders Iran to the east and Pakistan to the west and north (Central Intelligence Agency-The World Factbook, 2012). The country’s terrain mainly consists of rugged mountains, although there are plains in the southwest and northern parts. Summers in Afghanistan are hot, while winters can get extremely cold. The climate in Afghanistan is mostly arid-semi-arid, and only about 12% of the country is arable land (Central Intelligence Agency-The World Factbook, 2012).

Population

Afghanistan had an estimated population of 30,419,928, as of July 2012 (Central Intelligence Agency-The World Factbook, 2012). The current population estimate has been significantly revised, considering that it is based on an extrapolation of the country’s 1979 census that was disrupted by the Soviet invasion of Afghanistan (Central Intelligence Agency-The World Factbook, 2012).

Government

Afghanistan is an Islamic republic that gained independence in 1919 from the United Kingdom (UK) control. The country is governed by its sixth constitution which was ratified on January 26, 2004(Central Intelligence Agency-The World Factbook, 2012). Afghanistan has a mixed legal system consisting of Islamic, civil, and customary law.

Economy

The World Bank Group (2004) has classified Afghanistan as a low-income country. Decades of conflict have weakened the economy. Poverty levels are high, and Afghanistan still heavily relies on foreign aid (Population Reference Bureau, 2012). As of 2011, the country has a Gross Domestic Product (GDP) of $ 30.11 billion, while the inflation rate was at 7.7 %. At the same time, Afghanistan’s Gross National Income Purchasing Power Parity (GNI PPP) Per Capita was estimated at $ 860 against a global average of $ 10,240 (Population Reference Bureau, 2012).

State of Health

There are a number of hindrances to the provision of proper medical care in Afghanistan including war and economic and physical barriers like lack of access roads (Wilson 2011). Cavendish (2010) notes that rugged terrain in most rural Afghanistan and the lack of roads hinder the ability of women to access health facilities. Under-5 mortality rate stands at 257 for every 1000 live births (Bainbridge, 2010). A survey conducted in 2010 by The Afghanistan Mortality Survey revealed maternal mortality rates of less than 500 deaths for every 100,000 live births (BBC News, 2011). For every eight Afghani women, one dies due to pregnancy and child-birth-related complications every year (Wilson 2011). This is indicative of inadequate access to basic health care and poor environmental conditions. A formal birth registry by the Afghanistan government is lacking, and this makes it extremely difficult to report the infant mortality rate.

Since the Taliban regime was overthrown in 2001, the Afghanistan government, along with donors, has been working hand-in-hand to create a nationwide healthcare system (Cavendish, 2010). Nevertheless, underfunding is still rife, with most Afghanis being required to pay out-of-pocket when visiting health care facilities. Viswanathan et al. (2010) state that by 2005, infant mortality rate in Afghanistan stood at 165 deaths for every 1000 live births. However, this has now reduced to 77 deaths for every 1,000 live births as of 2011 (BBC News, 2011). Still, a significant number of children in Afghanistan are in dire need of emergency health care, as noted by Horsley (2009).

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Key Determinants of Health

Individual: Genetic make-up, sex, age

Harsh living and geographical conditions in Afghanistan have resulted in inter-marriages among tribes in Afghanistan. Genetic diseases could come about as a result of the right familial combinations (Bolt & Schoneboom, 2010). One of the genetic diseases prevalent in Afghanistan is Thalassemia major.

Social environment

Owing to decades of war, the Afghanis society has been ravaged by low economic status, especially among children and women (The World Health Organization, 2011). Gender inequality puts women at risk of health complications as they have less access to or control over resources. They are also not involved in health care decision making (The World Health Organization, 2011). Lack of education also affects women in Afghanistan because education brings in income and hence enhances security (Ministry of Public Health Afghanistan, 2012). The Taliban rule does not allow Afghanistan women to attend formal education and as such, 70% of girls are still not enrolled (World Food Program, 2012). This has resulted in a 12.6 % literacy rate among women (Wilson, 2011). Also, only female health care providers are allowed to care for women in Afghanistan and owing to their small number, this hinders women’s access to healthcare. Abuse of women by family members is an acceptable practice in Afghanistan, with most of them sustaining serious injuries and burns that affects their health (Wilson, 2011). Low literacy rates in Afghanistan, coupled with sociocultural barriers and the absence of knowledge as regards contraceptive methods and maternal health has resulted in reduced use of contraceptives and high maternal rates (Haider et al., 2009).

Healthy Behaviors and coping skills

Afghanis’ health behaviors are lacking as very few households have traditional latrines and practices like hand washing that improve hygiene and prevent diseases are almost never practiced (British Red Cross, 2012). Smoking in Afghanistan is quite prevalent like in the rest of the Arab world (World Health Organization, 2008). Afghanis are coping by coming together and forming groups of volunteers that educate people on the best way to stay healthy. Organizations are also digging latrines for proper disposal and wells to provide clean water (British Red Cross, 2012).

Physical environment

Afghan cities like Kandahar, Kabul and Mazar-i-Sharif have high levels of pollution. For every three Afghans living in urban areas, only one of them has access to improved sanitation while in the rural areas, 9 out of 10 Afganis are faced with poor sanitation (United National Development Programme, 2012). Nearly 50,000 children below five years of age in Afghanistan die every year due to diarrhoeal disease, according to estimates by UNICEF (2006). Afghanistan is among 20 countries in the world that have been worst hit by the national burden of disease as a result of indoor air pollution (World Health Organization, 2012). Afghanistan is also one of the 10 countries in the world where indoor air pollution is linked with over 1.5 million deaths every year. Solid fuels are the leading cause of indoor air pollution. The Lancet ranks Afghanistan and India among the high mortality regions for indoor air pollution with 95% of the population utilizing slid fuels for cooking, resulting in 400 000 deaths annually (Burki, 2011).

Among common types of labor in Afghanistan is child labor. Children work in agriculture, carpet weaving and construction sites, and soldiering among others. There they are exposed to pesticides and dangerous machinery and are made to carry heavy loads. Those who work on the streets face severe weather, accidents and fatalities (United Nations High Commission for Refugees, 2010).

Access to Health Services

With 36% of the Afghanis population living below the poverty line (World Bank Group, 2012), most Afghanis have no access to basic health services. In addition, most of the Afghanis pay for health services out-of-pocket (Cavendish, 2010) and owing to their modest income, even the most basic health care is not affordable.

Governance, Policies, and Interventions

Government policies and interventions affect social determinants of health by overcoming health inequalities. The availability of a highly bureaucratic system in Afghanistan, coupled with a limited national budget and human resources in the health care sector, hinders the provision of quality health care (World Health Organization, 2012).

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Key Health Status Indicators

A report by UNICEF (2009) showed that Afghanistan had a maternal mortality rate of 1,800 deaths for every 100,000 live births, while a report by BBC News (2011) indicates that it has reduced significantly to below 500 deaths for every 100,000 live births. Traditional customs in the country still hamper maternal care. Many deliveries take place at homesteads and in the absence of trained birth attendants, this leads to high maternal deaths (Guidotti et al., 2009). According to UNICEF (2010), Neonatal mortality rate in Afghanistan is at 45 deaths for every 1000 live births. However, in the absence of reliable data, it becomes very hard to prioritize on the most cost effective interventions to this problem (The World Health Organization, 2011).

Burden of Disease

In Afghanistan, the incidence rate of communicable diseases is still high. For example, the annual incidence rate of Tuberculosis in Afghanistan is 46 000 cases. The prevalence for Tuberculosis (TB) among women is higher than in of men (World Health Organization, 2011). Although there is a lot of effort towards facilitating child immunization exercises, these efforts have only managed to attain between 70 and 80 percent coverage. Nonetheless, the Ministry of Public Health in Afghanistan, along with health partners, has been making good progress in malaria control campaigns since 2007 (World Health Organization, 2011). Maternal and perinatal conditions in Afghanistan are among the poorest in the world. One out of every six pregnant women in Afghanistan is at risk of dying during childbirth (UNICEF, 2008).

A study conducted by Dott et al. (2005) showed that out of 15,509 deliveries carried out in Afghanistan hospitals within 12 months, the perinatal mortality rate was 56 for every 1000 births, while the deliveries led to 28 maternal deaths. Because a proper functioning health system is lacking in Afghanistan, this makes it hard to reduce such mortalities by improving maternal health care.

Non-Communicable Diseases (NCDs) are a leading cause of death in Afghanistan. For example, a report by the World Bank (2011) indicates that in 2004, NCDs, along with injuries, were responsible for 46 percent of total lives lost in Afghanistan owing to “ill-health, disability, and early death” (DALYs) (The World Bank Group, 2011). The other 52 percent was due to child and maternal issues, and communicable diseases. Injuries, and more so road traffic accidents, are the second leading cause of (DALYs) after cardiovascular diseases (World Health Organization, 2011).

Traditional Medicine

Traditional medicine still remains the primary form of treatment in remote rural areas of Afghanistan owing to lack of health clinics and transportation. Besides, traditional medicine is cheaper than that found in hospitals and as such, poverty forces most Afghanis to seek traditional treatments. Herbalists and bonesetters possess useful skills useful in the treatment of common ailments. However, most of them lack any professional training. As such, their treatment could lead to further illness, serious injuries, and possibly death (Sahak, 2010).

Healthcare System and Delivery

Although the health care system is currently in a state of disarray, there are efforts to rebuild it, spearheaded by the Afghanistan government through the Ministry of Public Health with the assistance of the US government and a number of NGOs (Acerra et al., 2009). The country has a total of 6 medical colleges with a total student enrolment rate of 11,000. The country also has 9 Institutes of Health Sciences where between 2,500 and 3,500 medical students have been enrolled (Acerra et al., 2009). Nevertheless, the country is still grappling with medical health problems. Nurses in Afghanistan are represented by the umbrella body of Midwives and Nurses Council (World Health Organization, 2007).

Health Priorities

The afghan government, through the Ministry of Public Health in Afghanistan is committed to providing all Afghans with better health services with a view to improving the country’s social and economic development. To do so, the country has identified and prioritized several needs that require to be addressed as a matter of urgency (Ministry of Public Health, 2012). The key health priorities in Afghanistan include reducing newborn and maternal mortalities, minimizing under-5s mortalities, in addition to enhancing provision of healthcare to newborns, reducing incidence and prevalence rate of communicable diseases, developing a working and efficient health care system. Other health priorities include reducing cases of malnutrition in the country, addressing mental health needs of the Afghanis, ensuring that noncommunicable as well as communicable diseases have been controlled in the Afghanis population, and increasing response to emergency preparedness due to disease outbreak.

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Nursing Implications

Nurses in Afghanistan are crucial in addressing the aforementioned health priorities in the country by training Afghanis women midwives because most of the traditional midwives have not been trained properly and this has contributed to the high rates of maternal deaths in the country. Such training would be aimed at reducing maternal mortality (Bainbridge, 2011). In addition, nurses can play a crucial role of

organizing education outreach programs aimed at sensitizing the Afghani men and women on the importance of embracing beneficial healthy behaviours such as avoiding smoking and attending prenatal clinics during pregnancy. This would help to reduce respiratory health diseases and infant and maternal deaths (World Health Organization, 2010). This can also be involved in

organizing mobile clinics to rural Afghanistan as most of the Afghanis are unable to get to hospital due to poor road and transport networks

The shortage of nurses in Afghanistan is quite severe and more so women nurses. The ratio of nurses to doctors is 1:1. The country has 7.26 nurses for every 10,000 Afghanis. This is by far below the 23 doctors, nurses and midwives per 10,000 persons recommended by the World Health Organization (World Health Organization, 2012). Some of the nursing organizations in Afghanistan include Afghan Nursing Association and the Midwives and Nurses Council.

Conclusion

This paper has reported on mortality in Afghanistan, a country located in southern Asia. With an estimated population of 30, 419,928, this Islamic republic has a legal system consisting of Islamic, civil and customary law. It is a low income country due to decades of conflict. The country’s economy is showing a marked improvement but is still threatened by insecurity, weak governance and criminality. The state of health in Afghanistan is adversely affected by lack of access roads, war and underfunding of health facilities. Key determinants of health in Afghanistan include geographical conditions leading to intermarriages and subsequently genetic diseases. Other determinants include social and physical environment, health behaviors, and working conditions. Key health indicators used here to gauge Afghanis’ health include child mortality rate which is the third highest in the world and maternal mortality rate which is also high. 46% of the burden of disease lies in NCDs and disability while 52% results from child and maternal issues and communicable diseases. Although the primary form of treatment is traditional medicine, modern health facilities are being rebuilt by identifying health priorities and having nurses train, organize and assist mobile clinics.

References

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Bainbridge, J. (2010). Afghanistan: the ‘worst’ place in the world for pregnant women. British Journal of Midwifery, 18(7), 447.

Bainbridge, J. (2011). Hope for women in Afghanistan as new midwives are trained. British Journal of Midwifery, 19(1), 47-48.

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Bolt, J.D., & Schoneboom, B. A. (2010). Operative splenectomy for treatment of homozygous thalassemia major in Afghan children at a US military hospital. AANA J., 78(2), 129-33.

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Dott, M. M., Orakil, N., Ebadi, H., Hernandez, F., MacFarlane, K., Riley, P.L., Prepas, R., & McCarthy, B. J. (2005). Implementing a facility-based maternal and perinatal health care surveillance system in Afghanistan. J Midwifery Womens Health, 50(4),296-300.

Guidotti, R. J., Kandasamy, T., Betran, A.P., Merialdi, M., Hakimi, F., Van Look, P., & Kakar, F. (2009). Monitoring perinatal outcomes in hospitals in Kabul, Afghanistan: The first step of a quality assurance process. J Matern Fetal Neonatal Med., 22(4), 285-92.

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