Dr Nadera Hayat Burhani

By Carmel Dolan, ENN

ENN interview with Dr. Nadera Hayat Burhani, Deputy Minister for Health Care Services Provision, Islamic Republic of Afghanistan

Dr Burhani speaking at International Day of the Midwife (2012)

In February 2012, I interviewed Dr Nadera Hayat Burhani, Deputy Minister for Health Care Services Provision, Ministry of Public Health (MoPH), Islamic Republic of Afghanistan for Field Exchange. Dr Burhani was a guest speaker at the CMAM Conference held in Addis Ababa, Ethiopia in November 2011¹. It was at this event that I met Dr Burhani and agreed to a Field Exchange profile on nutrition in Afghanistan and Dr Burhani’s experiences of working in such a complex environment.

Dr. Burhani is a medical physician (obstetrics and gynaecology speciality) and holds a Masters in International Public Health. As Deputy Minister for Health Care Services Provision, she is responsible for overseeing all aspects of nutrition from prevention to treatment of malnutrition in emergency and development situations. Previous to her current appointment in September 2008, she was Deputy Minister for Reproductive Health and Maternal and Child Health for three and a half years, following a clinical career as a gynaecologist/ obstetrician and physician in Balkh Province, Afghanistan.

Q: How would you describe the current nutrition environment (policy, resources, coordination, visibility and programmes) in Afghanistan?

The current policy environment is, Dr Burhani explained, responsive to the current needs and priorities of the country. The nutrition policy and strategy has been developed as part of health and nutrition sector strategy, which falls under the Afghanistan National Development Strategy (ANDS). Based on this policy, different programmatic guidelines have been developed to facilitate implementation of the policy. For example, guidelines on the Management of Acute Malnutrition, Infant and Young Child Feeding (IYCF) and Micronutrients have been developed recently².

She described how two national legislations have been developed and endorsed by the Cabinet, one in support of breastfeeding and for the control of marketing of breast milk substitutes and the other, for Universal Salt Iodisation (USI). According to these two national legislations, two national committees comprised of representatives of different sectors have been established to oversee the implementation of related programmes through a multi-sectoral approach. We have to, she emphasizes, work on the food safety and quality control policies and guidelines, as well as the dietary guidelines, for Afghans in the near future.

In terms of financial resources, we are in a good position. The main donors of the MoPH are USAID, the World Bank, and the European Union (EU), who are financing the primary health care services and nutrition is a key component. Also, the Canadian International Development Agency (CIDA) has committed to three years funding to support implementation of nutrition activities through the primary health care system. UN partners are supporting the MoPH to manage emergency response.

In terms of technical resources, we have a department at the MoPH with technical staff to support the implementation of nutrition programmes according to the national priorities and policies. This department plays an important role in the stewardship role of the MoPH to develop guidelines, policies, strategies, provide technical assistance for implementing partners, coordinate efforts with different stakeholders and sectors and monitor the current programmes. The MoPH is planning a long term strategy to develop more technical capacity in nutrition in the near future. Links have been established with the University of Massachusetts (US) and the London School of Hygiene and Tropical Medicine (UK) to provide opportunities for a team of Afghan professionals to obtain a Master’s degree in nutrition. Discussion with the Kabul Medical University, Cheragh Medical University and the American University of Afghanistan is on-going to establish a pre-service education programmes on nutrition (bachelor degree).

The key programmes in nutrition are USI, IYCF and the prevention of micronutrients deficiencies. These programmes are at different stages of development to reach national coverage. Our USI programme is a success story. It started in 2003 and we now have an average of 61% coverage of iodised salt utilisation at the national level with above 90% coverage in the main cities. For IYCF we have had pilot projects and based on lessons learnt, we are going to scale up the programme to reach each breastfeeding mother and her family in the country. Our micronutrients supplementation programme is mainly done through health system structures and here we need to work more to reduce iron, zinc, folic acid, vitamin C, and vitamin A deficiency.

Coordination is a challenge, especially as there are several actors. Dr. Burhani observed that nutrition is a multi-sectoral activity and requires involvement of several actors from the government, UN, donor agencies and implementing partners. To coordinate efforts at different levels require serious steps. She described how they are going to address this challenge through different approaches. ‘Nutrition Partners’ is a committee comprised of the main donors, UN agencies and some technical agencies, where partners discuss programmatic issues in terms of nutrition, especially developmental interventions. The Nutrition Cluster is another forum gathering UN agencies, NGOs and government partners to deal with emergency situations. Another two good examples she had already mentioned: the national committee for promotion of breast-feeding and a national board for USI that brings representatives from different government sectors, UN agencies and some other organisations to coordinate efforts.

In terms of how technical support is realised, a Nutrition Advisory Committee made up of experts in nutrition, provides technical advice to the MoPH through the Public Nutrition Department. "Overall, we ensure that we coordinate all partners’ efforts to address the national priorities in terms of nutrition and we believe that we are on the right track. Visibility of current nutrition programmes are not at a satisfactory level. Still the dominant mentality about nutrition programmes is only treatment of acute malnutrition. The other programmes are in their infancy stages and we need to work a lot to create awareness regarding the other programmes, especially with regards to IYCF and micronutrients".

Q: What are the main priorities for nutrition in the coming years?

The main priorities for the coming years are:

• Nutrition promotion through awareness raising, counselling, participatory demonstrations and community support activities implemented.
• Infant and Young Child Feeding, especially early initiation of breastfeeding, exclusive breastfeeding until six months, restricted use of commercial infant formula and respect of the International Code of Marketing of Breast Milk Substitutes, continued breastfeeding until 2 years and beyond, and introduction of solid/semi-solid foods at six months.
• Micronutrients including nutrition education, adequate fortification of staple foods and micronutrient supplementation.
• Adequate care during severe acute malnutrition treatment through in-patient care in hospitals for complicated cases, and outpatient care from hospitals or Comprehensive Health Centres for non-complicated cases.
• Food safety and quality control to ensure all foods made available to Afghan consumers, whether produced by the households, purchased on local markets, or imported, should be safe for consumption and respect national food safety and food quality standards.
• Effective nutritional surveillance and monitoring. Information on the nutrition situation and on the results and impacts of nutrition interventions should be regularly collected and analysed as part of relevant surveillance and monitoring and evaluation systems.
• Capacity development for public nutrition. Public nutrition training should be part of pre-service and in-service training for all health workers, and relevant staff working in the fields of agriculture, education, women’s and youth affairs, economics and social affairs.

Q: What are some of the main opportunities and the challenges for advancing nutrition?

Among the main opportunities is commitment of the leadership in the MoPH. There is a committed and competent team in the public nutrition department and we have commitment of donor agencies to support nutrition related activities. The Basic Package of Health Services (BPHS) is a system to deliver main services to all villages of the country.

The main challenges for advancing nutrition in the country are a shortage of technical cadres of nutrition staff, lack of institutions to generate nutritionists and experts in dietetics, dependency on donor financing and the security situation. Also, Afghanistan as a traditional society with several culturally rooted taboos on food consumption, low awareness on proper nutrition practices and barriers toward women status in the society create other challenges. In addition, many people live in very remote and often inhospitable mountainous areas making access at certain times of the year very difficult, if not impossible.

Q: With respect to the position of women, what impact is this having on their and their children’s nutritional status?

It is obvious that social status of women has a direct effect on their health and nutrition status and on their children. Our priority target groups in nutrition programmes are children and women. Raising awareness through different channels, ensuring that all programmes are gender-friendly (taking all special needs and cultural issues into account), messages and activities are socially and culturally sensitive and trying to involve men in all activities that require women’s participation, such as IYCF, is vital. Men are the decision makers in the Afghan society.

Providing services such as blanket food distribution, targeted supplementary feeding programmes and treatment programmes for women are the main steps we are taking to address this challenge. We are also trying to increase the age at which a girl marries to 16 years - today it is not uncommon for girls to be married at the age of 12 years. There is also a very high level of violence against women, especially in rural areas where many are also illiterate. Thus, there is a vicious cycle of early adolescent pregnancies which increases their risk of mortality and infant and child malnutrition.

Q: Afghanistan is very complex and challenging environment, can you describe how this impacts on your work in nutrition and your efforts to address women’s issues?

One of the challenges in this complex environment is how to reach the women and adolescent girls to provide them with appropriate education and support in nutrition issues, especially in the remote areas. However, we have piloted projects in different parts of the country in the past years to involve women in nutrition related activities by organising them into community support groups for breastfeeding and family action groups for child survival. Using the lessons learned from these pilot projects, we can scale up activities at the national level and use this opportunity also to improve the social status of women among their communities. We are going to conduct a study on nutrition programmes targeting adolescent girls in partnership with the World Bank. This project is in its very early design stages and we hope to learn some important lessons from it to scale up our interventions targeting adolescent girls.

We have made real progress in reducing both the under-five mortality and infant mortality rates over the past ten years and we need to continue this progress though addressing nutrition related problems.

Q: How well supported is Afghanistan by external donors and agencies for nutrition advancement and will Afghanistan become part of the Scaling Up Nutrition (SUN) movement?

Currently, nutrition programmes in Afghanistan are well supported by external donors. UNICEF, WHO, WFP and FAO are the active UN partners and supporters of nutrition activities. We have already started preparation of a ‘multi-sectoral plan of action for nutrition’ involving five key sectors (Health, Agriculture, Education, Rural Development and Commerce). The plan is in its draft stage and we hope that it will be launched officially by the end of the current fiscal year. To oversee the implementation of this plan, a committee at the Cabinet level will be established hopefully with the leadership of the Vice-President. A Secretariat will manage and coordinate the activities which will be supported by the World Bank. These are the steps to Scaling up Nutrition as a national development agenda.

Q: Is there anything else you would want readers of Field Exchange to know about nutrition in Afghanistan?

Malnutrition in Afghanistan is a consequence, as well as a cause, of widespread poverty. The people of Afghanistan have suffered from decades of war, instability and violence, which have led to greater poverty. This poverty is in turn worsened by the consequences of inadequate nutrition and affects future generations as well. Thus, combating malnutrition in Afghanistan is not only a humanitarian and survival issue but a development issue and a key strategy to eliminate poverty. We need to work hard with a long term vision to free the future generations of Afghans from the vicious cycle of poverty-malnutrition as we did in reducing maternal and child mortality rates during the past 10 years. We are confident that with a focused and coordinated effort, we can do more in the field of public nutrition. There is already support and commitment from the international community in this regard, which we are grateful for, and we hope that this international cooperation and partnership will continue so that we can contribute to the development goals.

Q: Is there a memorable moment in your professional career that you would like to recount?

When I arrived to work in the Ministry in 2005, I came from a regional hospital and was faced with a huge amount of decision-making responsibilities. I slept very little in the early days but when I became Deputy Minister, I was part of the team to work on reducing infant, child and maternal mortality which was like a ‘quiet tsunami’ needing urgent attention. A great personal moment was being part of the team to announce to the media the reductions in infant and maternal mortality achieved after ten years of dedicated efforts - a reduction in maternal mortality rate from 1,600 per 100,000 to 327 per 100,000, in the under 5 mortality rate from 257/100,000 in 2002 to 97/100,000 in 2010 and in infant mortality rate fron165 to 77 per 1,000 live births.

For more information, visit the MoPH website: www.moph.gov.af

¹See footage of Dr Burhani’s presentations at www.cmamconference2011.org

²Available at www.moph.gov.af