Dr Eric Laroche, Asst. DG, Health Action in Crises and Peter Graaff, WHO, Country Representative
KABUL - Transcript of press conference in Kabul by Dr Eric Laroche, Assistant Director-General for Health Action in Crises, World Health Organization (WHO), Peter Graaff, WHO Representative in Afghanistan, and Dr Nilab Mobarez, UNAMA spokesperson.
DR NILAB MOBAREZ : Good morning and thank you all for coming. Today, our guest speaker is Dr Laroche from WHO, Assistant Director-General for Health Action in Crises. We also have with us Peter Graaff, the Country Representative for WHO. But, first we have some information to share with you on the UN special envoy, Staffan de Mistura’s first six weeks in Afghanistan.
SRSG de Mistura has concluded his first six weeks in office as top UN envoy for Afghanistan. He left on Thursday to attend various meetings outside the country, including the North Atlantic Council meeting of NATO troop contributors to Afghanistan, on 23 April in Tallinn, Estonia.
The SRSG said: "I made a presentation of UN plans to support the Afghanization aspirations and activities of President Karzai and the Afghan Government. I was especially pleased to see the strong support by NATO Foreign Ministers to the crucial role the UN is expected to have this year in the fields of aid coherence, elections, regional dialogue, national reconciliation…"
During his first month on the ground, the SRSG paid visits to UN offices and local authorities in Gardez, Khost, Mazar-i-Sharif and Maimana to renew the support of the United Nations system for their efforts in bringing peace to Afghanistan.
At a town hall meeting with all UN staff in Kabul, he also encouraged them to renew their commitment to working for the people of Afghanistan.
His message to Afghan leaders and the public has been that he and the UN would continue to devote full support to an Afghan-led peace and development process.
He pledged that UN support would continue to be delivered in both peaceful areas and in those where UN staff and their Afghan counterparts are working hard for Afghanistan at no small risk.
SRSG de Mistura met several times with President Hamid Karzai. They covered a range of topics and have been working together to come to effective solutions to the ongoing electoral issues, including the composition of the Electoral Complaints Commission.
On 17 April, he recommended the commencement of technical and logistical assistance by the international community for parliamentary elections to be held in September 2010, following the President's concurrence with implementation guidelines proposed by the SRSG to help ensure credible and transparent elections. He then met on 19 April with the newly-appointed Chair of the Independent Electoral Commission, Fazel Ahmad Manawi, to discuss the same issues.
Mr de Mistura has also offered the UN's technical and logistical support to the upcoming Peace Jirga and Kabul Conference.
On 3 April, Mr de Mistura addressed scores of deminers at the annual observation of the International Day of Mine Awareness and Assistance in Mine Action, noting their courageous work to make Afghanistan safe and free of residual explosive devices.
He has kept up an intense schedule of meetings with many other senior Afghan officials, civil society representatives, diplomatic colleagues and military commanders. He also met with a delegation of Hezbi-i-Islami in Kabul on 25 March to discuss the reconciliation process.
SRSG de Mistura, with his newly arrived deputy for political affairs, Martin Kobler, has also been busy sharpening the focus and priorities of the UN Assistance Mission in Afghanistan.
In summarizing his first month as the Special Representative of the UN Secretary-General, he said: "The desire of the people of Afghanistan for peace is unmistakable. I have had fruitful meetings with the President and other senior officials, as well as with members of the opposition, civil society and the international community. And I have begun travelling around the country. I believe all whom I met want to make progress over the next year to turn the corner on conflict and to implement the Afghan agenda for peace and development. We are working in full support of that agenda, as and when requested by the Afghan leadership and people.”
“In the coming months, you should see a more focused United Nations system, better organized to offer that assistance. I will also be consulting with Afghanistan's neighbours on how they can better support our mutual goals for a stable and peaceful Afghanistan."
AFGHAN WINS PRESTIGIOUS UN ENVIRONMENTAL AWARD
We are proud to announce that the Afghan Director-General of the National Environmental Protection Agency, Prince Mostapha Zaher, has been awarded the UN's highest award for environmental leadership in Seoul, South Korea.
The 2010 Champions of the Earth Award, presented to six people from across the world, recognizes individuals who display commitment and vision on environmental leadership through their actions. This award is given out annually by the UN Environment Programme (UNEP).
DEHSABZ DISTRICT IN KABUL GETS A NEW COMMUNITY CENTRE
Over 47,000 people in Kabul province’s Dehsabz district will benefit from a community centre jointly built by the Government and UNDP. District Development Assembly members will be able to conduct their planning meetings and shuras there, while the local community will also get a venue to resolve their problems in a peaceful manner. The project, funded by the Government of Japan, was built at a cost of US $170,000.
RELIEF UPDATE: SAMANGAN EARTHQUAKE
A convoy of 28 trucks carrying relief items was sent to the earthquake-affected districts of Darisuf Bala, Darisuf Payeen and Roy Doab of Samangan province on 24 April.
The convoy comprised 16 trucks of food items: wheat, cooking oil, salt, beans and fortified biscuits sent by WFP. IOM also sent five trucks of non-food items such as cooking sets and other basic household items, while Care International’s seven trucks of quilts, hygiene kits and tarpaulins arrived at the three district centres, where distribution began under the supervision of a commission composed of the Afghan National Disaster Management Authority (ANDMA) and representatives of aid agencies.
A 5.3 magnitude earthquake hit Samangan’s three districts: Darisuf Bala, Darisuf Payeen and Roy Doab, last week.
DR ERIC LAROCHE (WHO): I have come here today to call for an intensified response to Afghan health humanitarian challenges. It’s my first return to Afghanistan since I left and I found a lot of changes. You’ve achieved a lot, but there are still obstacles that I would like to discuss today. First, you face a lot of obstacles, like natural disasters - yesterday I was in Samangan - but you also have to face the problem of conflict and of people who are migrating. So all these make the work of health workers extremely difficult and that of humanitarian workers as well.
I was pleased to see the development of Basic Package of Health Services (BPHS). It’s a programme that has worked well and has deployed a lot and has been able to bring a lot of health services to people in rural areas. There are still problems and we would like to see real outcomes of these efforts.
The purpose of this programme is universality. It means that each and every Afghan has the right to health; it is important because none of the Governments, no country in the world, can afford to serve its entire population.
In this time of globalization and international social injustice, WHO, two years ago, revised and revisited its primary health care programme, which is reformed and which again calls for everyone in the world to have access to health. It is extremely important, because the more we grow, the more there is inequity in health. Inequity brings social tension and social tension brings conflict.
More needs to be done and more needs to be supported financially. When you look at infant mortality rates, under-five mortality rate and maternal mortality rate, these are still extremely high. In spite of all these efforts that have been made and continue to be made, we have challenges. They are huge. We can be extremely good at reaching the goals that we want to reach. The challenge is also increasing so I think we need a lot of renewed effort and from the part of everyone, particularly from the donor community. It is important to realize that health is one of the components of peace. If people don’t have access to immunization, or to surgery, if people do not have access to treatment of diseases, they get frustrated. They see the difference between those who have access and those that do not and it is extremely important to recognize that nowadays in Afghanistan we can increase this access which was not the case some years ago when I was here, so that is extremely important.
So, what needs to be done? First we need to continue to have more health workers and these health workers need to be neutral. This is something that WHO would like to address and we discussed that yesterday with the Ministry of Public Health (MoPH). We need to have more health workers and particularly more nurses and midwives. If you look at the ratio between the number of doctors and number of nurses, this is imbalanced; we need to have almost twice as many nurses and midwives than we have today compared to the number of doctors. That doesn’t mean that the number of doctors is enough, but it has to be balanced, otherwise the work cannot be done properly.
Our WHO staff went last week to Badakhshan to the remote areas, far from the capital, and what they noticed is the benefit of having mobile teams. This is another strategy that could be easily done, providing we have the funding. The mobile strategy means that when you have a health centre somewhere and people are coming to it, providing they can. But, if you do not have access to these health centres because you are too far away, you use outreach services. From time to time they send someone there who is going to stay with the community, deliver the services and come back. But you cannot go too far away, so the only way to reach those people who are situated far away is to have mobile teams.
There are mobile teams in Badakhshan doing a wonderful job. They bring services from one place to another. They are mobile people going from one village to another. That can easily be expanded, because one of your challenges is not only conflict, not only natural disasters, but also the geographic challenge. We need to find innovative ways by which we will be able to deliver universal services to everyone.
Today, in southern Afghanistan, there is a conflict that is not new and the problem is that people cannot get access as they were able before to health services and they are afraid sometimes and they are also displaced and displaced to different cities of Afghanistan, particularly to Kabul. It means that Kabul has to cater to the increase of supplementary people and that hasn’t been budgeted and that needs to be budgeted for in the few weeks and months to come. Then there will be a revision of the Humanitarian Action Plan.
We hope we can face these new challenges so that we will be able to provide health services to all. As you know, in southern Afghanistan, there are three provinces: Helmand, Uruzgan and Kandahar that are in conflict today. Out of these three provinces there are particularly 13 districts where we encountered problems of access, access to everything including to immunization whereby everyone has to be immunized. There are seven cases of polio that are persistent that make Afghanistan a country that cannot be polio-free today.
Let me conclude by making a special mention on security of the health staff and health facilities. It’s a growing problem in Afghanistan. It is also a global problem. In many of these crises in the world, statistics show that the more we grow, the more insecurity incidents are occurring in the health sector, be it for health staff or health facilities. There is an international humanitarian law that says that you are not supposed to use health services for the purpose of fighting, so military or anyone else does not have the right to gather or stock ammunitions in schools and hospitals. This is more frequent all around the world. It is extremely important for the simple reason that if you are a humanitarian actor, if you are a health worker, and a health professional, you have an oath that says that we have to treat everyone regardless of nationality, religion and social reasons. It is also extremely important in Afghanistan. If one does not want to respect these international humanitarian laws, it’s going to be extremely difficult in the coming months and years to ensure that everyone will have access to health services and the right to health.
QUESTIONS AND ANSWERS
PAJWOK [translated from Dari]: How do you assess the health status in Afghanistan? In which field do you find problems in terms of health services here? My second question is, that based on the Ministry of Health’s statistics, one mother is losing her life, by giving birth, every half an hour. Has there been anything done to tackle this problem?
DR LAROCHE: At an overall level, I have not been here for several years, and when you come in and you travel, you see the difference. The difference is between what was in 2002 in Kabul - and the places I visited in the north - and what has become today. It’s obvious that there has been a lot investment, a lot of changes. I visited a few health service facilities and I saw huge differences that have taken place. There is no doubt that even though the challenges are huge and the indicators are still bad, first of all, we need to measure these indicators. Many indicators are from several years ago, like 2007, and even earlier. I am not sure if they are extremely different, but better.
Second, I have had a lot of discussions with different actors and it is clear that nowadays there are new challenges. Urban health is a challenge. Kabul has completely changed. When I left Kabul there were about 1.5 million people living in the city, now it is almost 4 million. It’s really difficult to absorb all these new people in terms of health issues.
Also a good indicator is immunization. In 2002, we were immunizing 4 million children. So it has almost doubled. We need to go beyond what is today: 7.5 million. Yet, it shows that a lot has been achieved and therefore we should see differences. There are differences, but at the same time there are challenges, and I am highlighting the growing insecurity. It is more difficult to go to some parts of Afghanistan. It is more difficult to have access to health than before.
There may be challenges that are new and other challenges are older ones. The Ministry of Public Health is beating for more maternal mortality budget. The international community and the people of Afghanistan may not understand that more is needed in the field of health. Actually much more is needed in the field of health in Afghanistan. If you look at statistics around Afghanistan and compare it to the countries in the region, you still have some distance to go. We cannot continue having imbalance. We are working in a globalized world. We’ve done a good job but it’s not enough. There are new challenges and we need to do more.
Responding to your second question, MoPH is right. There are too many women who are dying. The problem is of financing. Maternal Mortality Rate (MMR) programmes are a problem globally. Donors, for whatever reason, don’t finance enough. At this time last year, I made a point in Geneva that none of the maternal health (programmes) had been funded in June 2009 and that is absolutely not normal. So I need you to report that, because it is important that people finance these programmes. We know how to prevent the death of women.
GRAAFF: I would like to add something to this question. I remember that not long ago a number of you were here when, together with UNICEF and UNFPA, we launched The State of the World Children’s report. We discussed the very high levels of maternal mortality and, as Dr Laroche indicated, the very high figures for Afghanistan are not new. In fact the baseline for this is almost eight-years-old. I am pleased that this year MoPH and its partners will be focusing on maternal mortality to get a better understanding as to what are the levels of MMR and what are the levels by provinces or districts. Because it’s not going to be the same in all parts of the country. What we hope and expect is that the figures will have come down somewhat from those very high figures from before, like around 1600 nationwide and more than 6000 for Badakhshan.
Another issue I would like you to report is that it is not just only the health sector that should be strengthened when it comes to maternal mortality. It is also the issue around poverty, it is the education of women, it is livelihoods, empowerment, and this is also why doing it right will enhance the position of women in society and create benefits beyond maternal mortality.
NOOR TV [translated from Dari]: Given the nine-year assistance provided for the health sector so far, it seems challenges are still remaining. In remote areas people do not have access to health centres or health services. If there is a health centre or health facilities in the region and if there are qualified doctors, there is no good equipment. And if there is good equipment then there are no qualified doctors. This problem has been seen even in Kabul. I want to know the reason why despite all this assistance over the last nine years, there is no change in the health sector. Is that because of the weakness of MoPH or the fault of the international community?
DR LAROCHE: Peter Graff will better respond to that. But I can tell you that when you see the challenges we had in 2001 or 2002, these were huge challenges. Not only to bring the health workers here to work, but also to recreate all these structures. So I think a lot have been done, there is no doubt about that.
GRAAFF: Let me try to add to this. Dr Laroche can give you some sort of comparison to eight years ago. I have been here for only two years. What I can share with you is the fact that the system that was set up during that period - Dr Laroche was in the country - which is Basic Package Health Service (BPHS) is now a model that Afghanistan can proudly present internationally and which has been exported to other counties. Does that mean all people have access to quality health services? No. That’s why we still work together closely under the leadership of the Ministry of Public Health to advance their services. So I don’t think there is complacency among any of the partners. We realize there are still challenges ahead of us.
BBC: Do you have any specific statistics that show how many Afghans has access to the health sector in Afghanistan, particularly in the south part of the country. Are you concerned about this condition? Second part of the question is: What should WHO do to solve this problem and how they can help the Afghan Government in this area?
GRAAFF: First of all, when it comes to ‘numbers of people with no access to basic health services due to conflict-related issues,’ I have to start by admitting that we are not very good at this time in quantifying the numbers and assessments to get with number of partners not only on health, but also access to other basic social services planned for this year. Working figures indicate that half a million people needs urgently this type of access. What sort of intervention then are we thinking about?
Dr Laroche mentioned mobile health teams that go in when it is possible with qualified staff. That is good for areas where there are geographic problems, but they can also be used in areas that are problematic in terms of conflict. The second approach is the use of the private sector and we are at the moment piloting the use of private sector providers of health services for our basic services in some parts of the south, especially in Farah and Uruzgan. The third component is to rely more on the access that some of our NGO partners of BPHS project implementers have in specific districts. Last, a very important component, especially for basic services, is to talk directly to the community, community leaders, and mullahs and see whether we can, for specific areas in the country, expand the services delivered, for instance, through health workers. None of these interventions will work everywhere and we carefully need to look at possibilities on a district by district basis in order to ensure an increase access.
Yes, we are all concerned about health conditions in the country. A lot has been accomplished over the past eight years. Should we be happy where we are now? No, because there are still many men, women and children dying unnecessarily and we need to continue to work to improve their conditions.
VOA [translated from Dari]: I would like to know more about BPHS.
GRAFF: Well, BPHS is called Basic Package of Health Services and it is a system whereby province by province, one group - and this is in most cases an NGO and in some cases it is MoPH - is tasked to provide basic health services to the people. We're talking about health centres and health posts and these partners of the Ministry sign a contract that specifies what services need to provided and what money is made available to provide these services.
And every year, there is an independent group - in this case it is Johns Hopkins University - that does an analysis of the performance of the implementers of the services and they prepare a score card, which is like a report card, and based on that the contracts with the service provider gets renewed or sometimes not. BPHS started in late 2002.
SABA TV [translated from Pashto]: As far as Kabul is concerned, you mentioned the population is increasing day by day and so is pollution. What can be done in this regard? My second question is that the military here uses laser rays, which have harmful side effects. What can be done about this? My final question is about the H1N1 virus. There were rumors about it and people were scared. This is over now. What are the reasons behind it getting over?
GRAAFF: When it comes to the rapid expansion of Kabul and the problems of pollution, this is an issue that has health implications, but is not only linked with MoPH. We discussed with the Minister yesterday the importance of urban planning, which needs to bring together different ministries, including health. We're talking about water, sanitation, and exhaust fumes from cars and generators, etc. To our knowledge, the master plan on how Kabul needs to develop needs further development.
As for your second question, I cannot give an answer. I don't know if there are any negative consequences of equipment being used by the military for communication, etc. Of course, if somebody gets a laser ray directly in the eye it may affect eyesight. But I cannot give you an answer now. If you want, we can investigate this and we can let you know later.
To your third question on the H1N1 outbreak at the end of last year, they were not rumors. We have seen quite a few cases especially in the bigger cities such as Herat and Kabul and especially, interestingly enough, in healthy young adults, mainly men. But the numbers that we originally predicted globally - through modeling - were higher than the numbers we saw in country, as was the case in a number of other countries. The other good news was that those who caught the disease, in most cases, did not get very sick. So, H1N1 was there but it was not as severe as we all had feared at the outset of the epidemic. The response was relatively swift, especially in terms of treatment. But, at the end, we were lucky that the severity was not that high. However, it may come back. When the cold season enters at the end of the year, we have to be vigilant whether or not there will be a second wave of this epidemic.
SABA TV [translated from Pashto]: Can you give us numbers on how many people were infected?
DR LAROCHE: You were asking what is working well in Afghanistan. You have one of the best disease early warning systems in the region. I think you should be proud of that and this really helped a lot to do surveillance of this new disease. It's extremely difficult to know how many people contacted H1N1 and got sick.