This presentation was given by Sundaram, Steinhardt, Peters and Rahman to the International Health Economics Association Conference 2009 in Beijing. It is research conducted as part of the Future Health Systems Research Programme Consortium www.futurehealthsystems.org.

1. Obstacles to maternity service use
in Afghanistan:
what do we know about
cost, quality and access?
Sandhya Sundaram, Laura Steinhardt, David H. Peters,
M. Hafizur Rahman
Johns Hopkins Bloomberg School of Public Health
July 14, 2009

2. Background (1)
 Poor maternal and neonatal health outcomes
 High maternal mortality - 1,600 deaths/100,000 live
births nationally
(Range: 400/100,000 - 6,500/100,000)
 Estimated 70-80% maternal deaths due to
preventable causes
 Low maternal health service utilization levels
 Skilled antenatal care service use:
14% (2003 MICS) → 28% (2006 AHS)
 Skilled birth attendance:
13% (2003 MICS) → 19% (2006 AHS)
 Wide rural/urban gaps

3. Background (2)
 Accessibility to public sector maternal health
services greatly improved
 Capacity to provide services has increased from
23.4% to 71.9% of public sector facilities
 Supply of maternal health care services has
increased, but utilization does not seem to
have kept pace.
 Physical and financial accessibility still
problematic

4. Data Sources – Quantitative
 National Risk & Vulnerability Assessment (NRVA) 2005
 Poverty and vulnerability survey - LSMS with MCH
module
 Multistage cluster sample
 Almost 31,000 households
 Data presented today: ~13,500 deliveries in
previous 2 years
 Health Financing Pilot Intervention Project (HFP) 2007
 Evaluation of health financing pilot project –
community health insurance, user fees
 Cluster sample in 24 health facility catchment areas
 1,158 households across 49 clusters

5. Data Sources – Qualitative
 Community Health Worker Study 2006
 Focus group discussions (FGDs) with facility health
committees, community health committees, and
community members
 Focus on community perceptions of CHWs
 Maternal Health Care Service Utilization Study 2007
 Semi-structured interviews, FGDs
 Variety of respondents
 Data presented today – focus on women and men in
communities, and women using facilities and their
companions

6. Methodology – Analysis
 Survey data
 Bivariate analyses
 Multivariate analyses
 Qualitative data
 No audio-taping for security reasons
 Transcription and translation
 Coding
 Textual analysis

7. Access I
** p<0.01; *** p<0.001
Note: ORs adjusted for reproductive history, wealth status, access to credit, province, and other factors
Source: National Risk and Vulnerability
Assessment (NRVA) Survey 2005.

8. Access II
 Distance the most-often reported barrier to service use
 Cited by 75% of facility patients and companions; 92% of FGDs
 Services within 7 hrs’ walking distance considered accessible
 Poor access to transportation severely restricts service use
 2/3 of facility patients; 3/4 FGD participants
 Even when facilities are near, trained staff not always available
 CHWs a valued source of delivery services
 Nearly 2/3 of CHWs surveyed in 2005-2007 reported assisting with
home deliveries
 Community members suggested CHWs need adequate supplies,
drugs, and a salary to be more helpful

9. What do people say about access?
I don't go to clinic for delivery because my delivery
takes a short time. The clinic is far away and there is
no care to use and it is possible that delivery occurs in
the middle way. Other people also have the same
problem… I have lost 3 of my children because after
delivery, the placenta is not delivered soon and I have
too much bleeding. But because of the distance and
problem of transport, I cannot go to the clinic.
(Facility patient, female, 30 yrs., 2007)
Source: 2007 maternal health service use qualitative study

10. Cost I
** p<0.01; *** p<0.001
Note: ORs adjusted for reproductive history, travel time, province, and other factors
Source: National Risk and Vulnerability
Assessment (NRVA) Survey 2005.

11. Cost II
 User fees for curative care deterred use of maternal
health services
 Use of facility for delivery greater among households
w/ fee waiver card (despite free delivery care)
 0.12 deliveries in last 6 months per household w/o
waiver card vs. 0.29 w/card, (p=0.001)*
* Controlling for province, wealth, walking distance to facility, and facility type
Sources: 2005 NRVA and 2007 HFP Evaluation survey .

12. Cost III
 More than half of facility patients and their companions,
and participants in more than half of FGDs, reported
household poverty and high care-seeking costs as
barriers to skilled attendance at delivery
 Service costs relatively standard for primary care, but vary
substantially for secondary and tertiary care
 Drug and transportation costs highly variable
 Financial costs of care-seeking—service costs (private), drug
costs, transportation costs and baksheesh—are prohibitive
 Household poverty—financial poverty and lack of access to
credit—prevents women from using services
 In emergencies, households often have to seek loans to
support care-seeking and may experience difficulty securing
funds
Source: 2007 maternal health service use qualitative study

13. What do people say about cost?
Respondent 9: I have gone to the clinic once for
check up, but they did not give me
medicine, and give me the
prescription for the bazaar,
however we our economy is too
weak then I could not buy these
medicines.
Respondent 10: I got information from the midwife,
and she told me you must get some
… medicines, and it will cost about
1000 Afghanis, but I [did] not have
the amount and the clinic did not give
me medicine.
(Focus group discussion, child-bearing age women)
Source: 2007 maternal health service use qualitative study

14. Quality
 Most respondents feel availability & quality have
improved
 Respondents care about how providers treat patients
 Being treated with respect; privacy and female
providers for female patients
 Drug availability and effectiveness matter
 Some respondents feel they have been properly
treated only if they receive drugs
 Perceptions of poor drug quality or low stock may
cause clients to seek care elsewhere
 Respondents appreciate fairness in facility procedures
 Seeing patients in order, emergency patients first
 Reports of patronage systems resulting in inequitable
access
 Female providers and 24-hour access are important
Source: 2007 maternal health service use qualitative study

15. Conclusions
 Distance – compounded by transportation
availability – emerged as top barrier to maternal
health service utilization
 Non-services costs (e.g., medication,
transportation, baksheesh) can be strong
deterrents to care-seeking
 Lack of female providers, lack of privacy, and drug
stock-outs were important barriers to care-seeking

16. Policy recommendations
 Need to address accessibility issues, particularly
times of service availability, availability of skilled
care for home-based deliveries, and transportation
availability
 More focus on birth planning, so households are
prepared for regular births and for emergencies
(e.g., emergency funds, transportation)
 Re-think role of CHWs in delivery (e.g., stronger
links to midwives, incentives for facility referral)

17. Thank you
Acknowledgments: Johns Hopkins University Technical Assistance
Project, Future Health Systems: Innovations for
Equity, Ministry of Public Health (Afghanistan), Central
Statistics Office (Afghanistan)
Author contact info: Sandhya Sundaram: ssundara@jhsph.edu
Laura Steinhardt: lsteinha@jhsph.edu
David Peters: dpeters@jhsph.edu
M. Hafizur Rahman: hrahman@jhsph.edu

18. Discussion
 Factors that were difficult to measure accurately:
 Security/conflict (in quantitative data)
 NRVA Data limitations
 Missing data in NRVA
 One province (Zabul) missing due to security
 Unable to link to age of women in HH register (used
age at marriage)
 Other issues to consider:
 ??

19. What do people say about quality?
They pay attention to the customs of people. Today I
came from the hospital. I saw they were paying
attention to all customs of people. Female doctors
were checking female patients, and male doctors were
checking male patients and female section was
separated form the male section. No activity of the
doctors is against the custom of people.
(Facility patient, female, 24 yrs., 2007)
Source: 2007 maternal health service use qualitative study

20. Access, cost & quality intersect:
illustrations
 Access and cost
In my opinion their [CHWs’] service during delivery is most
useful not only for me, but for all of village’s residences,
since we all are poor people and can’t afford to get a taxi for
our patient to take her to the clinic or hospital, at mean time
we call CHW and she is always ready to serve for us during
the night as well as during the day.
(Female community member, Balkh province, 2006)
 Access, cost and quality
Respondent: I do not want to come to the clinic or if it is
needed then we go to the _____ bazaar.
Interviewer: Why? Can you describe it?
Respondent: Because the distance to the clinic is too long, and
it is the same [services provided when we] go to
_____ bazaar. They cost equal.
(Facility patient, female, 35 yrs., 2007)
Sources: 2006 CHW perceptions study and 2007 maternal
health service use qualitative study.