Afghanistan confirmed its first case of COVID-19 in late February 2020. The country’s porous borders with early COVID-19 hotspots, particularly Iran, coupled with decades-long protracted conflict, high poverty rates, and a challenged health system contributed to quickly escalating COVID-19 transmission across the country.

WHO’s support to the Ministry of Public Health’s (MoPH) COVID-19 response commenced even before the first case was detected, to help Afghanistan get ahead of the COVID-19 curve and protect gains made in health. Building on successful practices during previous health emergencies and other countries' experiences, WHO started assisting the MoPH in January 2020. This support included the provision of technical guidance for pandemic preparedness, facilitation in the development of the National Emergency Response Plan for COVID-19, recommendations for implementing effective risk communications and community engagement and outreach to donors for aligning funds for the response.

Leading a united effort against COVID-19

Foreseeing the disastrous consequences of COVID-19 on the already fragile health system and the knock-on social and economic impacts, the UN in Afghanistan came together as one in an unprecedented way to respond to the pandemic. The UN agencies, funds and programmes aligned their efforts to ensure a coordinated technical, operational and financial multi-sectoral support to the Government. WHO was instrumental in driving this united effort forward. It consistently provided guidance, evidence and standards to guide the work and decisions of the UN COVID-19 crisis team and led the development of the ONE UN COVID-19 Health Response Plan in May 2020, which presented the roadmap of the UN’s support, focused on three areas: i) health, led and coordinated by WHO, ii) humanitarian support coordinated by UNOCHA the Humanitarian Coordinator, and iii) social protection and economic recovery assisted by the World Bank and UNDP. This plan was updated in June 2020 and has continued to guide the UN’s COVID-19 response in Afghanistan and in the wake of the first wave of COVID-19 provided a financing platform through which the UN, donors, and the private sector channelled US$ 69 million to curb the pandemic’s impact.

Expanding testing and improving health workers’ capacity

Enhancing COVID-19 testing capacity across the country has been a core element of WHO’s assistance. When the outbreak first began, there was no COVID-19 testing facility in Afghanistan. In coordination with the MoPH, WHO has since supported the establishment and expansion of 22 public testing laboratories. These can collectively perform 7,100 tests per round and up to 21,300 tests per 24 hours, if needed. More than 250 laboratory staff have been trained on PCR testing as part of the efforts to enhance testing capacity. Plans are in place to continue this rapid laboratory expansion and ensure that by June 2021 each province has at least one COVID-19 testing facility with appropriately trained staff.

To meet the demand for, and maintain a steady availability of, essential laboratory and medical supplies and equipment, the country team has been working closely with WHO’s regional office and headquarter. This helped ensure timely assistance even during instances of global shortages of PPE and testing kits, such as experienced in the early stages of the pandemic. WHO is working with UN agencies, funds and programmes to ensure that the ongoing procurement efforts are well-coordinated at the country level. A procurement tracking system established and maintained by WHO prevents duplication of procurement and distribution efforts and enhances transparency and accountability in resource alignment. In turn, this helps legitimise the UN’s efforts to contain and respond to the pandemic.

To date, WHO’s total contribution of supplies and equipment handed over to the MoPH stands at approximately US$13 million, which most notably includes 1054 oxygen concentrator machines, 38 ventilators, 54 PCR machines, PCR testing kits and supplies, more than 20 million masks (surgical and respirator masks) and almost 6 million gloves. An estimated US$7.5 million worth of additional COVID-19 supplies and equipment is in the pipeline.

Building health workers’ capacity to respond to COVID-19 and protect themselves and patients is at the heart of WHO’s response. To date, almost 4,000 health workers have been trained on infection prevention and control and 2,400 have received training on ICU and case management of COVID-19 patients. The improved capacities of the health workers and the supplies and equipment provided to hospitals and isolation centres are contributing to ensuring the provision of appropriate clinical care for patients and a safe environment at health facilities for all.

These investments will have long-term payoffs by playing a crucial role in improving and strengthening the quality, availability, and access to essential health services beyond the COVID-19 pandemic.

Rising to the challenge to enhance surveillance

The scale and rapid spread of COVID-19 necessitated urgent strengthening of the National Disease Surveillance and Response (NDSR) department, which has been functional since 2006. To successfully slow down the transmission and contain COVID-19, Afghanistan needed larger-scale surveillance to identify and sample suspected cases. WHO played a significant role in the expansion and capacity building of the Rapid Response Teams (RRTs) managed by the NDSR. To date, more than 300 RRTs (compared to just 34 RRTs functional before the pandemic) have been trained and mobilised to support contact tracing and referrals. Surveillance training has also been provided to more than 30 Fixed Response Teams (FRTs).

WHO’s support for enhancing disease surveillance included provision of global guidelines on surveillance, case definitions, contact tracing and the development of a locally adapted training curriculum for the RRTs. In addition, financial and technical support has been provided to improve the electronic data management and reporting of COVID-19 cases including a mobile SMS system used for relaying results to people tested for COVID-19.

With extensive population movements between Afghanistan, Iran, and Pakistan, WHO has supported in limiting cross-border transmission of the virus by strengthening screening at points of entry (PoE) including airports, ground crossings, and provincial checkpoints. More than 320 PoE staff have been trained on screening and provision of health messages. To date, WHO, in collaboration with the MoPH and the International Organisation for Migration (IOM), has screened 6.9 million people at various PoEs.

As one of the largest health initiatives in the country, the Afghanistan polio programme has been supporting the COVID-19 response as part of its commitment to contribute to public health in general. In February 2020, the programme halted polio campaigns to avoid COVID-19 transmission. However, during this time it quickly repurposed itself and stepped up to support COVID-19 surveillance and community awareness using the wide reach of the existing polio networks. Though polio campaigns safely resumed in September 2020 after a six month pause, the polio programme continues to support the pandemic response.  Since March 2020, the programme has trained almost 35,900 members of the Polio Surveillance Network, almost 61 600 frontline polio workers, more than 37 100 health professionals, paramedics and nurses, and approximately 1700 government and NGO staff on COVID-19 and polio surveillance. This has enabled the programme to report more than 62 000 suspected COVID-19 cases of which, 9100 have been confirmed positive. Almost 31 700 community and religious influencers have been oriented on delivering public health messages, which is supporting in raising communities’ awareness of COVID-19 prevention and care.

Limiting the toll of COVID-19 by maintaining essential health services

COVID-19 severely disrupted essential health services throughout the country. For example, by mid 2020 the availability of antenatal care decreased by 25%, while essential surgery services decline by 41%. This worsened the provision of health care to some of the most vulnerable communities. To prevent one crisis leading to another, WHO promptly supported the MoPH in identifying and prioritising essential lifesaving health services in order to minimise interruptions.

Technical guidance and support were provided to urgently resume and strengthen critical services linked to reproductive, maternal, new-born and child health care, infectious diseases, routine immunisation, primary health care and trauma care. In collaboration with the Health Cluster, WHO also helped ensure the continued provision of essential medicines and medical supplies, as well as training and capacity building of health care personnel to deliver high-quality health services even during the ongoing pandemic.

As the preparation for vaccine rollout signals new hope in the fight against COVID-19, WHO will continue its efforts to strengthen essential health services to build a resilience health system that is capable of coping with future emergencies.

Lessons from the pandemic

One year since Afghanistan started responding to COVID-19, the Government supported by the UN has made significant strides in containing the pandemic and laying the foundations to strengthen the Afghan public health system. Still, more needs to be done.

Diagnostic testing remains a critical tool for pinpointing confirmed cases to prevent and slow down COVID-19 transmission. Therefore, the expansion of laboratories continues to be crucial for ensuring at least one testing facility per province as it can increase people's ability to access and take up testing, especially for those communities most vulnerable to COVID-19.

COVID-19 has shown that just pandemic preparedness is not enough to mount an adequate public health response. Maintaining and strengthening essential health care services, the health system’s first line of defense, is just as important to manage preventable illnesses and morbidities from rising. COVID-19 has exposed many gaps in the delivery and availability of such services.

Continued investments are needed to build a quality, resilient, health system by:

1. building health workers’ capacity for ensuring adequate clinic care for COVID-19 patients as well as improving their adaptability and preparedness for delivering health services during emergencies
2. developing health infrastructure and ensuring steady availability of medical equipment and supplies
3. improving access to primary health facilities as the first point of contact for medical assistance
4. removing barriers to equity to further consolidate the Universal Health Coverage agenda in Afghanistan.
   

Afghanistan has an opportunity to learn from its experience with this pandemic. There is an obvious need for more in-depth gap analysis, tabletop exercises, simulations and developing stronger contingency plans and mechanisms to cope with future emergencies, together with strengthening of the health system to provide high-quality, people-centered health services. Long term, predictable, support from the donor and the international community will be key in ensuring that the country not only copes with the health challenges arising from the pandemic but also achieves social and economic recovery in the long run.

Photo caption: Doctors trained on IPC and case management attend to a COVID-19 patient.

Photo credit: WHO