The need to sustain funding for Afghanistan health system to prevent excess morbidity and mortality.

Background: The Afghanistan Reconstruction Trust Fund, managed by the World Bank through a contracted-out instrument called Sehatmandi, financed health service delivery in Afghanistan, with substantial achievements in infant, child and maternal health. After the collapse of the Afghan Government on 15 August 2021, the health system has been on the brink of collapse. Aims: We assessed the use of basic health services and estimated excess mortality resulting from the interruption to healthcare funding. Methods: We conducted a cross-sectional study that compared health services utilization from June to September for 3 consecutive years, 2019, 2020 and 2021, using 11 output indicators reported by the health management and information system. We used the Lives Saved Tool, a linear mathematical model with input data from the Afghanistan Demographic Health Survey 2015, to calculate the additional maternal, neonatal and child mortality at 25%, 50%, 75% and 95% reduction in health coverage. Results: During August and September 2021, after the announced ban on financing, health service utilization decreased to a range of 7-59%. Family planning, major surgeries and postnatal care showed the greatest decreases. Uptake of child immunization showed one-third decrease. Sehatmandi provides around 75% of primary and secondary health services: pausing funds to this programme will result in additional 2862 maternal deaths, 15 741 neonatal deaths, 30 519 child deaths, and 4057 stillbirths. Conclusion: Sustaining the current level of health services delivery is crucial to avoid excess, preventable morbidity and mortality in Afghanistan.

Potential health impact and cost-effectiveness of bivalent human papillomavirus (HPV) vaccination in Afghanistan.

INTRODUCTION: Human papillomavirus (HPV) vaccination has not been introduced in many countries in South-Central Asia, including Afghanistan, despite the sub-region having the highest incidence rate of cervical cancer in Asia. This study estimates the potential health impact and cost-effectiveness of HPV vaccination in Afghanistan to inform national decision-making. METHOD: An Excel-based static cohort model was used to estimate the lifetime costs and health outcomes of vaccinating a single cohort of 9-year-old girls in the year 2018 with the bivalent HPV vaccine, compared to no vaccination. We also explored a scenario with a catch-up campaign for girls aged 10-14 years. Input parameters were based on local sources, published literature, or assumptions when no data was available. The primary outcome measure was the discounted cost per disability-adjusted life-year (DALY) averted, evaluated from both government and societal perspectives. RESULTS: Vaccinating a single cohort of 9-year-old girls against HPV in Afghanistan could avert 1718 cervical cancer cases, 125 hospitalizations, and 1612 deaths over the lifetime of the cohort. The incremental cost-effectiveness ratio was US$426 per DALY averted from the government perspective and US$400 per DALY averted from the societal perspective. The estimated annual cost of the HPV vaccination program (US$3,343,311) represents approximately 3.53% of the country's total immunization budget for 2018 or 0.13% of total health expenditures. CONCLUSION: In Afghanistan, HPV vaccine introduction targeting a single cohort is potentially cost-effective (0.7 times the GDP per capita of $586) from both the government and societal perspective with additional health benefits generated by a catch-up campaign, depending on the government's willingness to pay for the projected health outcomes.

Addressing health workforce shortages and maldistribution in Afghanistan.

BACKGROUND: Afghanistan has the second lowest health workforce density and the highest level of rural residing population in the Eastern Mediterranean Region. Ongoing insecurity, cultural, socio-economic and regulatory barriers have also contributed to gender and geographic imbalances. Afghanistan has introduced a number of interventions to tackle its health worker shortage and maldistribution. AIMS: This review provides an overview of interventions introduced to address the critical shortage and maldistribution of health workers in rural and remote Afghanistan. METHODS: A review of literature (including published peer-reviewed, grey literature, and national and international technical reports and documents) was conducted. RESULTS: The attraction and retention of health workforce in rural and remote areas require using a bundle of interventions to overcome these complex multidimensional challenges. Afghanistan expanded training institutions in remote provinces and introduced new cadres of community-based health practitioners. Targeted recruitment and deployment to rural areas, financial incentives and family support were other cited approaches. These interventions have increased the availability of health workers in rural areas, resulting in improved service delivery and health outcomes. Despite these efforts, challenges still persist including: limited female health worker mobility, retention of volunteer community-based health workforce, competition from the private sector and challenges of expanding scopes of practice of new cadres. CONCLUSIONS: Afghanistan made notable progress but must continue its efforts in addressing its critical health worker shortage and maldistribution through the production, deployment and retention of a "fit-for-purpose" gender-balanced, rural workforce with adequate skill mix. Limited literature inhibits evaluating progress and further studies are needed.

Re-evaluating the cost and cost-effectiveness of rotavirus vaccination in Bangladesh, Ghana, and Malawi: A comparison of three rotavirus vaccines.

INTRODUCTION: Diarrhea is a leading cause of mortality worldwide and rotavirus accounts for many of these deaths. As of August 2018, 96 countries have introduced rotavirus vaccines into their immunization programs. Two rotavirus vaccines, Rotarix® and RotaTeq®, have been WHO-prequalified since 2009, with Rotarix® being the preferred product of most Gavi-supported countries. ROTAVAC® and ROTASIIL® have both been prequalified recently. MATERIALS AND METHODS: We reevaluated the costs and cost-effectiveness of rotavirus vaccination in Bangladesh, Ghana, and Malawi and compared Rotarix®, ROTAVAC®, and ROTASIIL® in each country. For consistency with previously published analyses in these countries, we used the same Excel-based cohort model and much of the same data as the original analyses. We varied the expected price (with and without Gavi subsidy), wastage, and incremental health system costs associated with each vaccine. We assumed the same efficacy and waning assumptions following administration of two or three doses for the respective product. RESULTS: The discounted cost per DALY averted compared to no vaccination ranged from 0.3 to 1.3 times GNI per capita for each vaccine. With the Gavi subsidy, the average cost-effectiveness ratios were below 0.3 times GNI per capita in all three countries. Though critical empirical cost data are not yet available, Rotarix® is the least costly and most cost-effective product in the countries examined in this modelling study. However, small decreases in the incremental health system cost for other products could result in cost and cost-effectiveness outcomes that match or surpass those of Rotarix®. CONCLUSION: Countries may wish to consider new rotavirus vaccines entering the market. Countries should carefully examine multiple product attributes including price and the incremental health system costs associated with each vaccine. These costs will vary by country and may be a defining factor in determining the least costly and most cost-effective product for the population.

Rotavirus is the leading cause of hospitalizations for severe acute gastroenteritis among Afghan children <5 years old.

BACKGROUND: Rotavirus gastroenteritis is estimated to cause approximately five thousand deaths annually among Afghan children under 5 years old. Because laboratory confirmation of rotavirus is not routinely performed in clinical settings, assessing the precise burden of disease attributable to severe rotavirus gastroenteritis typically requires active surveillance efforts. This study describes the current burden of pediatric hospitalizations attributable to rotavirus gastroenteritis among Afghan children using surveillance data collected from 2013 to 2015. METHODS: Rotavirus surveillance was conducted from January 2013 through December 2015 at two of the largest hospitals in the country, Indira Gandhi Children Hospital in Kabul and Herat Regional Hospital. Children between 1 and 60 months of age who were admitted to these hospitals for diarrhea were consented and enrolled. Information on age, gender, and seasonality were collected. Stool specimens were collected and tested by enzyme immunoassay for the presence of rotavirus at the central public health laboratory in Afghanistan. RESULTS: Overall, 1,413 of 2,737 (52%) of hospitalized children under five years old with diarrhea were rotavirus cases. The overwhelming majority of rotavirus hospitalizations occurred in children younger than two years of age (93%) while 42% of all rotavirus hospitalizations occurred in children between 6 and 11 months of age. Rotavirus transmission occurred year-round. CONCLUSIONS: Rotavirus is a major cause of severe acute gastroenteritis hospitalizations in young Afghan children, responsible for over half of diarrheal hospitalizations in this population. The Afghanistan Ministry of Public Health has prioritized reducing child mortality by 2020 and is actively working towards the introduction of rotavirus vaccination in Afghan children. These data will be instrumental in understanding the potential impact upon child health that may be achieved through the introduction of rotavirus vaccines in Afghanistan.

Potential impact and cost-effectiveness of rotavirus vaccination in Afghanistan.

INTRODUCTION: Despite progress made in child survival in the past 20 years, 5.9 million children under five years died in 2015, with 9% of these deaths due to diarrhea. Rotavirus is responsible for more than a third of diarrhea deaths. In 2013, rotavirus was estimated to cause 215,000 deaths among children under five years, including 89,000 in Asia. As of April 2017, 92 countries worldwide have introduced rotavirus vaccination in their national immunization program. Afghanistan has applied for Gavi support to introduce rotavirus vaccination nationally. This study estimates the potential impact and cost-effectiveness of a national rotavirus immunization program in Afghanistan. METHODS: This study examined the use of Rotarix® (RV1) administered using a two-dose schedule at 6 and 10 weeks of age. We used the ProVac Initiative's UNIVAC model (version 1.2.09) to evaluate the impact and cost-effectiveness of a rotavirus vaccine program compared with no vaccine over ten birth cohorts from 2017 to 2026 with a 3% annual discount rate. All monetary units are adjusted to 2017 US$. RESULTS: Rotavirus vaccination in Afghanistan has the potential to avert more than one million cases; 660,000 outpatient visits; approximately 50,000 hospital admissions; 650,000 DALYs; and 12,000 deaths, over 10 years. Not accounting for any Gavi subsidy, rotavirus vaccination can avert DALYs at US$82/DALY from the government perspective and US$80/DALY from the societal perspective. With Gavi support, DALYs can be averted at US$29/DALY and US$31/DALY from the societal and government perspective, respectively. The average yearly cost of a rotavirus vaccination program would represent 2.8% of the total immunization budget expected in 2017 and 0.1% of total health expenditure. CONCLUSION: The introduction of rotavirus vaccination would be highly cost-effective in Afghanistan, and even more so with a Gavi subsidy.

Global, regional, and national prevalence of overweight and obesity in children and adults during 1980-2013: a systematic analysis for the Global Burden of Disease Study 2013.

BACKGROUND: In 2010, overweight and obesity were estimated to cause 3·4 million deaths, 3·9% of years of life lost, and 3·8% of disability-adjusted life-years (DALYs) worldwide. The rise in obesity has led to widespread calls for regular monitoring of changes in overweight and obesity prevalence in all populations. Comparable, up-to-date information about levels and trends is essential to quantify population health effects and to prompt decision makers to prioritise action. We estimate the global, regional, and national prevalence of overweight and obesity in children and adults during 1980-2013. METHODS: We systematically identified surveys, reports, and published studies (n=1769) that included data for height and weight, both through physical measurements and self-reports. We used mixed effects linear regression to correct for bias in self-reports. We obtained data for prevalence of obesity and overweight by age, sex, country, and year (n=19,244) with a spatiotemporal Gaussian process regression model to estimate prevalence with 95% uncertainty intervals (UIs). FINDINGS: Worldwide, the proportion of adults with a body-mass index (BMI) of 25 kg/m(2) or greater increased between 1980 and 2013 from 28·8% (95% UI 28·4-29·3) to 36·9% (36·3-37·4) in men, and from 29·8% (29·3-30·2) to 38·0% (37·5-38·5) in women. Prevalence has increased substantially in children and adolescents in developed countries; 23·8% (22·9-24·7) of boys and 22·6% (21·7-23·6) of girls were overweight or obese in 2013. The prevalence of overweight and obesity has also increased in children and adolescents in developing countries, from 8·1% (7·7-8·6) to 12·9% (12·3-13·5) in 2013 for boys and from 8·4% (8·1-8·8) to 13·4% (13·0-13·9) in girls. In adults, estimated prevalence of obesity exceeded 50% in men in Tonga and in women in Kuwait, Kiribati, Federated States of Micronesia, Libya, Qatar, Tonga, and Samoa. Since 2006, the increase in adult obesity in developed countries has slowed down. INTERPRETATION: Because of the established health risks and substantial increases in prevalence, obesity has become a major global health challenge. Not only is obesity increasing, but no national success stories have been reported in the past 33 years. Urgent global action and leadership is needed to help countries to more effectively intervene. FUNDING: Bill & Melinda Gates Foundation.