Poverty, vulnerability, and provision of healthcare in Afghanistan

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Abstract

This paper presents findings on conditions of healthcare delivery in Afghanistan. There is an ongoing debate about barriers to healthcare in low-income as well as fragile states. In 2002, the Government of Afghanistan established a Basic Package of Health Services (BPHS), contracting primary healthcare delivery to non-state providers. The priority was to give access to the most vulnerable groups: women, children, disabled persons, and the poorest households. In 2005, we conducted a nationwide survey, and using a logistic regression model, investigated provider choice. We also measured associations between perceived availability and usefulness of healthcare providers. Our results indicate that the implementation of the package has partially reached its goal: to target the most vulnerable. The pattern of use of healthcare provider suggests that disabled people, female-headed households, and poorest households visited health centres more often (during the year preceding the survey interview). But these vulnerable groups faced more difficulties while using health centres, hospitals as well as private providers and their out-of-pocket expenditure was higher than other groups. In the model of provider choice, time to travel reduces the likelihood for all Afghans of choosing health centres and hospitals. We situate these findings in the larger context of current debates regarding healthcare delivery for vulnerable populations in fragile state environments. The ‘scaling-up process’ is faced with several issues that jeopardize the objective of equitable access: cost of care, coverage of remote areas, and competition from profit-orientated providers. To overcome these structural barriers, we suggest reinforcing processes of transparency, accountability and participation.

Introduction

There is an ongoing debate among academics, policy makers, and practitioners regarding access to healthcare in low-income countries. Existing literature has examined associations between demand for healthcare and quality of service based on structural characteristics such as the existence of a service and number of available medical staff (Alderman and Lavy, 1996, Lavy and Germain, 1994). Some authors have studied the effect of quality variables: availability of drugs (Akin, Guilkey, & Denton, 1995; Lavy and Germain, 1994, Mwabu et al., 1993), number of staff (Akin et al., 1995, Lavy and Germain, 1994), or level of skills (Hotchkiss, 1993). Thus in Mali, Mariko (2003) looked at the impact of quality of care on health status of all patients and showed that availability of drugs, training, and sensitivity of medical staff had a positive effect on utilisation of public and non-profit facilities. Few studies, however, have investigated the impact of client perception of health services.

Our paper focuses on choice of provider for vulnerable groups and their perceptions regarding healthcare delivery. Measuring user satisfaction, the effect of quality on healthcare outcomes, and the choice of provider, can be well documented through client surveys (Lavy and Quigley, 1993, Mwabu et al., 1993, Sahn et al., 2003, Thomas et al., 1992). However, research is limited regarding how individual and household characteristics, health services structure, and cost of care, will impact perceptions of the relevance of the healthcare system especially through household based surveys. We agree with Glick (2009) that satisfaction ratings of clients in facility-based surveys are biased, and that subjective perceptions regarding the process (behaviour of practitioners, attitude of staff) can even be more strongly biased. There is little evidence of equitable access for the poor and disadvantaged, especially in fragile states (Filmer et al., 2000, Patouillard et al., 2007). We examine, for Afghanistan, how people from different social and economic backgrounds value the actual delivery of healthcare services, using data from a national household survey on disability.

Contracting health services delivery to non-state providers has become a widespread approach to implementing health services in developing countries (Bhushan, Keller, & Schwartz, 2002; Marek, Diallo, Ndiaye, & Rakotosalama, 1999; La Forgia et al., 2004, Palmer et al., 2006). Setting-up a basic healthcare system in a conflict-affected fragile state, which lacks the capacity to implement public health policies, especially those aimed at reducing inequalities, complicates an already intricate global health issue (Department for International Development, 2005, Loevinsohn and Harding, 2005, Soeters et al., 2006). Basic healthcare services include primary level services such as health posts, comprehensive health centres, community health centres as well as outpatients departments in district hospitals (Doherty & Govender, 2004). The overarching goal of contracting for primary healthcare delivery is to provide equitable, effective and efficient access. Studies show that contracting-out primary healthcare can address 90% of anticipated local healthcare needs (World Bank, 1994).

In 2002, seconded by a joint mission of donors (USAID, European Commission and World Bank) as well as WHO, UNICEF, and other development partners, Afghanistan's Ministry of Public Health (MoPH) developed a Basic Package of Health Services (BPHS) to address major health needs of the population. The BPHS is tailored to provide accessible, low cost, good quality healthcare, through health posts, basic health centres, comprehensive health centres and district hospitals. It covers seven priority health concerns: maternal and newborn health, child health and immunization, public nutrition, communicable diseases with concentration on tuberculosis and malaria, mental health, disability, and essential drugs. The system relies upon the principles of competition and performance-based contracting. Thus the MoPH contracted 27 non-government organisations (NGOs) covering 31 of the 34 provinces of Afghanistan to implement the BPHS (Loevinsohn & Sayed, 2008; Palmer, Strong, Wali, & Sondorp, 2006); it retained responsibility for service delivery in the remaining 3 provinces (MoPH, 2003). The MoPH retained overall stewardship of the health sector, defining priorities, monitoring, coordinating, and evaluating implementation of healthcare provision (MoPH, 2005).

Over recent years in Afghanistan, the focus has been on provision of cost-effective services, which have the greatest impact on major health problems in both rural and urban settings. Promoting equitable access meant combating discrimination in the delivery of care, effectively giving priority access to the population groups in greatest need (women, children, persons with disabilities, and those living in most severe poverty; MoPH, 2007). For example, many facilities charging user fees have exemptions for poor patients (MoPH et al., 2007). Alongside the BPHS, the private sector is composed of unregulated for-profit providers, both formal and informal, including clinics, medical practitioners, health practitioners, pharmacies, and small drug retailers. The cost of care can be high and the quality unpredictable, reflecting insufficient training (Sabri, Siddiqi, Ahmed, Kakar, & Perrot, 2007).

Access to healthcare is of particular importance in Afghanistan, because the health challenges for fragile states are significant. Decades of conflict have increased poverty, further aggravated by several droughts since 2001. Health indicators such as the maternal, infant and under five mortality rates are among the highest worldwide (Bartlett et al., 2005). There has been, of course, some improvement in access to healthcare, education, and safe drinking water (Beall and Schutte, 2006, WFP MRRD, 2004). Presently, eighty two percent of Afghans live in districts where primary care services are delivered by NGOs (Loevinsohn & Sayed, 2008). But this does not guarantee effective access: shortages of qualified health personnel, scarcity of finances, violence, and absence or deficiency of health infrastructure, especially in remote areas, remain major constraints (Bristol, 2005, Morikawa, 2008, Sabri et al., 2007).

Prior to our research, there has been periodic evaluations of the BPHS, assessing the outcomes of healthcare contracting arrangements, the determinants and client perceptions of quality of BPHS services (Hansen et al., 2008, Hansen et al., 2008). Previous authors documented an improvement in many indicators of quality of care between 2004 and 2006, reflected in increased numbers of new female outpatients, care deliveries, and exemptions for poor patients. Yet, they also reported that cost was mentioned as the main barrier to seeking care by the poor living in the catchment area of the facility (Steinhardt et al., 2009). Overall, they concluded that widespread improvements in service delivery had been made since 2002.

In this paper, we go a step beyond such an analysis, to determine the extent to which health service delivery contracted to non-state providers has improved access for vulnerable groups nationwide, and whether this represents local preferences. We examined local choice between all available providers, including traditional providers. Individuals who chose to visit traditional healers (called tibi unani) also visited elderly women (dais), mullahs and imams or a shrine for martyred Afghans who fought against the Soviets (ziarat). We also explored local perceptions regarding modern healthcare delivery: whether Afghans, especially vulnerable groups, value the BPHS provided by the MoPH as compared to the private sector. We investigated associations between provider choice and the characteristics of respondents and households, after adjustments for covariates such as providers' attributes. Furthermore, we explored factors underlining local perceptions of healthcare, and estimated their influence on provider choice. This approach is useful for policy makers, as it compares effective use against perceived utility. It thus contributes to a better understanding linked to effective healthcare provision.

Section snippets

Study design

We undertook a national cross-sectional multistage cluster sample survey on disability between December 2004 and August 2005. We used a three-stage cluster sampling corresponding to the division of Afghanistan in 34 provinces, 397 districts, and more than 30,000 villages. This provided a sample representative of all households in Afghanistan (Fig. 1). We set a limit of statistical significance (=0.05 with 95% confidence intervals), and assumed a prevalence of disability of 8%, a 10% precision

Access, difficulty, and expenditure

We highlight the main findings of healthcare usage, disaggregated by wealth status, gender of household head, and disability status. We observed significant differences in the burden of healthcare according to levels of poverty and vulnerability.

Fig. 2 shows that private providers were predominantly used by all Afghans. Individuals in the poorest wealth quintile were significantly more likely to visit a health centre (p < 0.001) but less likely to visit a hospital (p < 0.001) than were

Discussion

This paper provides evidence for a range of factors influencing choice of provider and local perceptions of the Basic Package of Health Services in Afghanistan. This contributes to the ongoing debate on equitable access to healthcare in complex environments and fragile states.

The contracting-out of healthcare in Afghanistan has yielded some positive outcomes. Our results demonstrate that the aim to meet the needs of vulnerable groups - female-headed households, children, the poor, the

Conclusion

Access to healthcare of vulnerable people is an important issue for policy makers and international donor agencies. Our results indicate that the health policy makers in Afghanistan have partially reached their goal: the most vulnerable groups used public health services at par or in some cases more than other users. However, our regression model does not show privileged access for all vulnerable groups, after adjustment for other factors. Difficulties such as inaccessibility, cost, shortage of

Acknowledgements

We would like to thank all the participants in this study, as well as monitors, supervisors and interviewers for their outstanding work in the field. We are grateful to Professor Nora Groce, Dr Maria Kett, Dr Ray Lang, Dr Veronique Alary and Nicki Bailey for their very useful and constructive comments along the way. We are also grateful to the three anonymous reviewers who made important suggestions to improve this paper. This study was funded by the European Commission, UNOPS/UNDP, UN Mine

References (67)

  • J.I. Litvack et al.

    User fee plus quality equals improved access to health care: results of a field experiment in Cameroon

    Social Science & Medicine

    (1993)
  • B. Loevinsohn et al.

    Buying results? Contracting for health service delivery in developing countries

    Lancet

    (2005)
  • M. Mariko

    Quality of care and the demand for health services in Bamako, Mali: the specific roles of structural, process, and outcome components

    Social Science & Medicine

    (2003)
  • E.R. Morey et al.

    Willingness to pay and determinants of choice for improved malaria treatment in rural Nepal

    Social Science & Medicine

    (2003)
  • B. Shengelia et al.

    Access, utilization, quality, and effective coverage: an integrated conceptual framework and measurement strategy

    Social Science & Medicine

    (2005)
  • P. Tibandebage et al.

    The market shaping of charges, trust and abuse: health care transactions in Tanzania

    Social Science & Medicine

    (2005)
  • A. Wailoo et al.

    The nature of procedural preferences for health-care rationing decisions

    Social Science & Medicine

    (2005)
  • H.R. Waters

    Measuring equity in access to health care

    Social Science & Medicine

    (2000)
  • V. Wiseman et al.

    Determinants of provider choice for malaria treatment: experience from the Gambia

    Social Science & Medicine

    (2008)
  • H. Alderman et al.

    Household responses to public health services: cost and quality tradeoffs

    The World Bank Research Observer

    (1996)
  • O. Ameli et al.

    Contracting for health services: effects of utilization and quality on the costs of the basic package of health services in Afghanistan

    Bulletin of the World Health Organization

    (2008)
  • L.L. Amowitz et al.

    Maternal mortality in Herat province, Afghanistan, in 2002. An indicator of women's human rights

    Journal of American Medical Association

    (2002)
  • Bakhshi, P., Trani, J- F. (2007). Vulnerability and basic capabilities deprivation: A gender analysis of disability,...
  • J. Beall et al.

    Urban livelihood in Afghanistan, synthesis paper series

    (2006)
  • I. Bhushan et al.

    Achieving the twin objectives of efficiency and equity: Contracting health services in Cambodia

    (2002)
  • E. Bloom et al.

    Contracting for health: Evidence from Cambodia

    (2006)
  • Department for International Development

    Why we need to work more effectively in fragile states

    (2005)
  • Doherty, J., & Govender, R. (2004). The cost-effectiveness of primary care services in developing countries: A review...
  • R.P. Ellis et al.

    Inpatient and outpatient health care demand in Cairo, Egypt

    Health Economics

    (1994)
  • C.C. Fair et al.

    Securing Afghanistan. Getting on track

    (2009)
  • D. Filmer et al.

    Weak links in the chain: a diagnosis of health policy in poor countries

    The World Bank Research Observer

    (2000)
  • D. Filmer et al.

    Estimating wealth effects without expenditure data-or tears: an application to educational enrolments in states of India

    Demography

    (2001)
  • P. Garwood

    Pakistan, Afghanistan look to women to improve health care

    Bulletin of the World Health Organization

    (2006)
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