Afghanistan Fact Sheet
Women's nutrition 15-49 years
THINNESS (2013)

Women who are thin (BMI < 18.5kg/m2)

9.2%
OVERWEIGHT OR OBESE (2013)
Women who are overweight or obese (BMI ≥ 25 kg/m2)

29%© UNICEF/2019/Elham

ANAEMIA (WRA) (2013)

A nutrition counsellor weighs
a mother and child at a healthclinic in Zabul province

Anaemia among women of reproductive age

40.4%

396

MATERNAL MORTALITY (2018)per 100,000 live births

23

NEONATAL MORTALITY (2018)per 1,000 live births

Addressing maternal nutrition service
delivery gaps in Afghanistan: Policy andprogramming opportunities
Dr Zakia Maroof is a Nutrition Specialist working with UNICEF Afghanistan.
Dr Homayoun Ludin is an Afghan doctor working with the Ministry of Public Health.
Dr Zelaikha Anwari is an Afghan doctor serving as a Reproductive, Maternal, Newborn, Childand Adolescent Health (RMNCAH) director in the Ministry of Public Health since February 2015.
Suzanne Fuhrman is a Nutrition Manager working with UNICEF Afghanistan.
Maureen Gallagher is Chief of Nutrition Section with UNICEF Afghanistan.

BackgroundAfghanistan is entering its fourth decadeof unrest and conflict; 40 years that haveleft an indelible impact on the country’s
women and children. The year 2018 was
especially challenging, with a spike in violence, unprecedented levels of drought
and food insecurity, increased poverty
and a higher number of security incidents compared to past years. Strategic
roads that link the different regions andprovinces have become highly insecure,adding complexity to programme implementation and further hampering theaccess of women and children to basic
health and social services. Over half ofthe country’s population (54.5%) live
below the poverty line1.
Although there has been much progress in the Afghan health system in thelast 15 years, the country continues tohave a fragile and challenging healthcare environment and still has among
the highest maternal and newborn mortality rates globally. Afghanistan also
has among the worst coverage of maternal and child health (MCH) services
in the world. Key indicators of service
coverage, such as receipt of four or more
visits of antenatal care (20.9%), women
who deliver in a health facility (56.3%),
and those who receive care from a skilled
birth attendant (58.8%), remain low2.
Only 37.4% of women receive any postnatal care from a skilled health provider,with major disparities and much poorer service provision in conflict-affected
and remote areas2. Other important barriers are poverty and women’s lack ofdecision-making power in the family.
NUTRITION EXCHANGE SOUTH ASIA

9Building an enabling
environment at the policy level

Afghanistan joined the SUN Movementin 2018, raising the nutrition agenda to ahigher political level. At the same time,it established a multisector nutrition
platform, the Afghanistan Food Securityand Nutrition Agenda (AFSEN-A), in
which 14 ministries, UN agencies andpartner organisations discuss joint work
to improve the nutrition situation in thecountry.
Several recent policy decisions show
an increasing national commitment tomaternal nutrition. Improving maternal nutrition is a core component of
the revised National Nutrition Strategy
12Afghanistan Living Conditions Survey (2016/17).
Afghanistan Health Survey (2018).

FIGURE 1 Health system links in Afghanistan
BPHS
Hospitals
T

MH
BHC

RH

MH

T

HSC

CHC

HP

DHHP
HP

BHC

HP

HP
HP
HP

HP
HP

PH

HP

BPHS
HP Health Post
HSC Health Sub-Centre
BHC Basic Health Centre
MHT Mobile Health TeamCHC Comprehensive Health TeamDH District HospitalHospitals
DH District Hospital
PH Provincial Hospital
RH Regional Hospital(2019-2023), and the National Nutrition

bile health teams, basic health centres,(2019-2023;

health sub-centres and health posts (thestill being finalised) includes specif-

latter being the lowest level of service

ic activities to address current gaps indelivery, where volunteer Community

Promotion Strategic Plan

the Ministry of Public Health’s (MoPH)

Health Workers (CHW) make home vis-nutrition promotion; for example, ad-its). The Essential Package of Hospital

olescent girls (aged 10-19 years) taking

Services (EPHS) was endorsed in 2005

iron and folic acid (IFA) weekly supple-to provide tertiary-level health services

mentation, and pregnant women taking

for all Afghan citizens.

IFA supplements during pregnancy are
key behaviours in the strategy.

BPHS and EPHS nutrition interventions for pregnant postpartum women

Maternal nutrition is included in theinclude: promotion of iodised salt andrevised Infant and Young Child Feedinga balanced diet of micronutrient-rich

Strategy, now called the Maternal, Infant,and Young Child Nutrition (MIYCN) Strategy.
Moreover, weekly IFA supplementation
for adolescent girls has been integrated into the National School Health Policy,
ensuring the continuum between adolescent and maternal nutrition. Weekly
IFA supplementation is currently available only for school-going adolescent
girls, but the 2019 plan includes expansion to out-of-school adolescent girls.

foods through health education sessions;
one-to-one nutrition counselling andfood demonstrations; and IFA supplementation. However, to date maternal
nutrition interventions have not beenprioritised by the non-governmentalorganisations that are contracted to implement the BPHS and EPHS, and there
are no specific indicators currently inplace to monitor intervention coverage. For example, antenatal care (ANC)

Packaging health services

visits are used as a proxy indicator for

Afghanistan has faced significant chal-that IFA is not always available in healthlenges in rebuilding its health system
in a fragile-state setting since theGovernment and international donors

IFA supplementation, despite evidence
facilities and distribution is sometimes
below the required recommendations.

the services that should be provided atImproving the continuum ofmaternal nutrition care inservice delivery

each level of primary healthcare facil-

One of the main gaps in the provi-

ity, which includes district hospitals,

sion of health and nutrition services

comprehensive

in Afghanistan was the provision ofand partners began the work in 2001.
The MoPH developed the Basic Packageof Health Services (BPHS) to delineate

healthcentres,

mo-NUTRITION EXCHANGE SOUTH ASIA

10

one-to-one counselling based on actual client needs. This was not always
possible due to the high volume of patients, time pressures for midwives andnurses, and the lack of counselling skillsof existing health staff. To address thisneed, in 2016 the MoPH approved therecruitment of paid female nutrition
counsellors for all primary healthcare
facilities in 18 out of 34 provinces.
Around 1,500 of this nutrition-specific cadre were recruited and received a28-day comprehensive nutrition training
package, including maternal nutrition.
Their services in the 18 provinces wereassessed before the initiative was expanded to the entire country. The resultsof this assessment confirmed that clientsregularly gave positive feedback on information and advice they received fromnutrition counsellors, and that the counsellors play a positive role in increasing
the awareness of nutrition practices.
Following this assessment, nutrition
counsellors are now being recruited forthe remaining 16 provinces. Based onrecommendations, a refresher trainingis planned for the cadre in the initial
18 provinces. In addition, UNICEF andother development partners have supported the recruitment of one mentor
per province to provide on-the-job support to nutrition counsellors as part oftheir one-year, capacity-building plan.

One-to-one nutrition counselling

The main role of nutrition counsellors
is providing individual counselling to
women who are pregnant, exclusively breastfeeding and/or nursing andfeeding young children. Counselling
includes promoting the consumptionof micronutrient-rich foods. Nutrition
counsellors coordinate with midwives,nurses and vaccinators to ensure there
are no missed opportunities to provide
nutrition information and advice towomen who visit the facility for different reasons. The nutrition counsellors
also provide outreach work and, wherepossible, attend CHW meetings andmeet with health shuras3 to share information on nutrition.
The nutrition counsellors will besupported through capacity-building
3

Health shuras are community volunteers (usually elders)
who meet to discuss health-related issues of communitymembers.

© UNICEF/2019/Sherzad

Counselling a mother on exclusive breastfeedingat a basic health centre in Jalalabad

programmes to improve delivery of activities at community level. It is hoped
this will assist in building awarenesson nutrition, including the importanceof maternal nutrition; not only for themothers themselves, but also for thewellbeing of their children. The counsellors are based in health facilities andlink with communities through community health supervisors, whose key role
is to supervise and mentor CHWs.

Strengthening service-provisionmonitoring and tracking

Nutrition counsellors are one of the contact points for distributing the Maternaland Child Health Handbook to women.
The handbook is the country’s first-everhome-based maternal, child, health andnutrition record. It combines birth registration, pregnancy monitoring, birthmonitoring, vaccination, growth monitoring and childhood-illness monitoring.
The handbook also includes messages onmaternal nutrition for easy reference
for women and families to read and put
into practice at home. It has been introduced in three provinces in 2019 andintroduction will expand in phases to allprovinces by the end of 2021.
The current policy is for pregnant
women to attend four ANC visits; however, there are plans to increase thisto eight ANC visits, as recommended
by WHO, although this may be difficult to achieve due to access issues tohealth facilities. One way to overcome
this constraint is to use the monthly growth monitoring and promotion
and food demonstration sessions of theCommunity Based Nutrition Package(CBNP)4 to provide a regular contact
point between pregnant women andCHWs at the community level. CHWs
are the volunteer health and nutrition service providers who are closest
to communities. However, many partners are working with the same CHWs
through convergent and coordinatedapproaches, which can sometimes overburden the workload of these volunteers.

Challenges to maternal nutrition
programming

Access is a particular challenge inthe insecure and fragile context ofAfghanistan, since government staff
and development partners are unable totravel to some parts of the country. Suchsecurity limitations make monitoring ofmaternal nutrition activities very difficult and affect the quality of the services
provided; for example, they mean restricted travel for the female nutrition
counsellor mentors recruited to provide
support to nutrition counsellors.
Administrative data on the coverageof maternal nutrition interventions islacking as there is currently no indicatorin the health management information system. It is important to address
this gap to elevate the importance ofand build greater accountability for thedelivery of maternal nutrition interventions in the health system. In addition,
impact indicators such as anaemia
prevalence are not regularly integrated into national health surveys. Other
challenges to improving maternal nutrition concern irregular supplies of IFA
in health facilities, which affects thecoverage and continuity of supplemenNUTRITION EXCHANGE SOUTH ASIA

11tation. The promotion of iodised salt
also remains an issue due to several factors, including the higher cost of iodisedsalt compared to regular salt.

Opportunities for scaling up
maternal nutrition services

The Government and its partners haveidentified several opportunities tointegrate all maternal and child nutrition-related activities in a unified
package, so that mothers and children
receive the complete package of services
at each contact point. After finalisationof the MIYCN strategy and operational
guidance, comprehensive training will
be provided to all relevant health staff
on all components of IYCF and caring,with the addition of maternal nutrition.
The nutrition counsellors have alreadybeen trained and deployed in 18 provinces, with recruitment in process forthe remaining provinces.
Linkage and referral between healthfacilities and communities through theCBNP for increasing antenatal coverage at community level are being
considered, including expanding four
ANC visits to eight ANC key contact
points. Finally, national information
systems are under review, which will bean opportunity to integrate indicators tomonitor the coverage of maternal nutrition interventions.
4

The CBNP includes regular home visits, aside from themonthly community gatherings, for those children
who are in the yellow bar (at risk category) of the growthmonitoring and promotion card. During these home
visits, the families will be followed up, consulted andencouraged to practice what they have learned during
the monthly community gatherings to help their children
gain weight.