154
Table 9.6: Youth literacy rate, by residence, and by sex in percentages; Gender equity indicators, by residence
Sex and gender National
Urban Rural
Kuchi equity indicators
a. Sex
Both sexes 51.7
74.3 44.6
12.5 Male
66.3 83.4
62.3 20.6
Female 36.7
65.1 26.5
2.6
b. Gender equity indicators
Absolute difference 29.7
18.4 35.7
18.0 Gender parity index
0.55 0.78
0.43 0.13
The literacy gender parity index is the ratio of the female literacy rate to the male literacy rate
for the age group 15-24. The indicator is applied in Afghanistan as an ANDS indicator to
measure progress towards gender equity in education and presents a key indicator of
empowerment of women in society. At national level, ALCS 2013-14 found a figure of 0.55 for this indicator see Table 9.6, indicating that the share of female youth that is able to read and write is just
over half that of male youth. The corresponding figures for urban and rural populations were, respectively, 0.78 and 0.43.
9.4.2 Developments in literacy levels
Despite large investments in the education system in the decade before the ALCS 2013-14, their conversion into increased literacy rates is a slow process. The adult literacy rate
– referring to the population 15 years of age and older
– has increased, from 26 percent in NRVA 2007-08 to 31 percent in NRVA 2011-12 data not shown and is now recorded at 34 percent Table 9.5. The successive
surveys observed an increase in the male adult literacy rate from 39 percent to 45 and to 49 percent, respectively, and in the female adult literacy rate from 12 percent to 17 and to 19 percent, respectively.
These figures imply that the targets defined in the Education Strategic Plan 2010-2014 of the Ministry of Education for 1393 2014 MoE 2010
– 48 percent overall literacy, and 54 and 43 percent for males and females respectively
– have not been achieved. Although the male literacy rate came close to the set target, the female rate fell short by more than half.
The youth literacy rates show modest, but constant improvement since the NRVA 2005
Figure 9.10
. This ANDSMDG indicator showed a 65 percent increase in the rate between NRVA 2005 and ALCS
2013-14 for both sexes combined. However, the tempo of the increase is far too low to even come close to the ANDS target of 100 percent in 2020.
ANDS Indicator 4.d Ratio of literate females to males 15-24 year olds
0.55
155
Figure 9.10: Youth literacy rate, by sex, and by survey year in percentages
Figure 9.11
presents the change in literacy levels based on age-specific literacy rates. It indicates an improvement in educational performance in the period since 2001. Educational improvement is
suggested by the increase of literacy rates in younger age groups at the left of the graph, an effect that is most clear for women. For all women aged 30 and over the literacy rate is 10 percent or below,
indicating that during the years in which they were in their school age educational opportunities were very poor. The up-turn that can be observed for women in their late twenties reflects the new
opportunities to enter the formal education system after the remove from power of the Taliban regime in 2001.
50
The increase in literacy continues for each successively younger age up to age 15. At this peak, 48 percent of girls is able to read and write and 71 percent of boys is able to do so. Children of
younger ages show somewhat lower literacy because of the effect of later school starters and using moving averages in the graph.
The changes in educational opportunities since 2001 directly affected the gender equity indicators. Although both girls and boys benefitted from improved access to school, the relative impact for girls
was much greater. As can be seen in Figure 9.10, the gender parity index
– the ratio of female-to-male literacy
– sharply increases from just over 20 percent for persons around 30 years old who were too old to effectively benefit from the change in 2001 to 70 percent for children around age 12. This figure
indicates that at this age the share of girls that is able to read and write is 70 percent of the share of boys that is able to do so. In absolute terms, the gap between the male and female literacy rates is fairly stable
around 36 percentage points from older ages up to around age 23 except for the age group 36 to 37, where the gap is somewhat smaller. At this age, also the absolute gap starts to decrease from 35 to
below 18 percentage points around age 12. This age-based assessment confirms that literacy for the younger generations in Afghanistan has improved, and that, relatively, girls benefitted more than boys
and have begun to catch up with them. Probably, in no previous generation has the gender gap for literacy been so small.
50
The age location of the up-turn in the late 20s is due to the combined effect of girls entering education at an advanced age, the application of five-year moving averages in the graph and age misreporting.
31 39
47 52
40 53
62 66
20 24
32 37
10 20
30 40
50 60
70
NRVA 2005
NRVA 2007-08
NRVA 2011-12
ALCS 2013-14
Both sexes Male
Female
156
Figure 9.11: Literacy rate, by sex, and by age; Gender equity indicators, by age
a
a
The series in this graph present five-year moving averages. 5
10 15
20 25
30 35
40 45
50 55
60 65
70 75
12 14
16 18
20 22
24 26
28 30
32 34
36 38
40 42
44 46
48 50
Age
Male Female
Absolute difference Gender parity index
157
10 HEALTH
Summary . The ALCS 2013-14 confirms the image of a recovering health system in Afghanistan since
the beginning of the century, even to the extent that in some areas it achieves performance levels not previously recorded. Although Afghanistan’s health indicators are poor in an international perspective
and cultural barriers and financial and security constraints impede progress for many components of health, significant improvement is evident from successive surveys in the post-Taliban period.
The present survey shows that improvement of the health care system remains one of the highest priorities for the Afghan people. Whereas prior to NRVA 2011-12 much progress was made in access
to health care in terms of time required to reach different types of health facilities, this trend seems to have continued only modestly for public and private clinics. Travel costs and other health-related
expenditures remain major obstacles for many people to obtain the care they need. ALCS 2013-14 shows that medical needs of one in every five women who were ill or injured, could not be met, mostly because
of poverty and geographical remoteness. Costs and transportation to access health services are also associated with cultural and social barriers at the demand side, which may limit the observed
improvement in the health sector. Cultural responsiveness of the health system
– for instance in terms of provision of female health care providers
– remains an obstacle for the effective use of health care, especially by women. However, the availability of female service providers has significantly improved
in the rural areas, especially through private clinics and public health posts. The most consistent and impressive improvements are observed for maternal health indicators.
Afghanistan has achieved its MDG target for ante-natal care coverage ahead of schedule, and in 2011- 12 already surpassed its MDG 2020 target of 50 percent coverage. ALCS 2013-14 indicated that 63
percent of pregnant women made at least one visit to a skilled ANC provider. However, the recommended four visits are realised by only 23 percent of pregnant women. Also with regard to the
percentage of institutional deliveries 43 percent and skilled birth attendance 45 percent ALCS 2013- 14 indicated a consistent improvement in recent years. The general trend in skilled birth attendance
suggests that the MDG 2015 target of 50 percent is within reach.
From the ALCS data, it is evident that breastfeeding in Afghanistan is almost universal 93 percent and typically continues for a long duration; practices that are very beneficial for both mother and child.
However, substantial health gains can be achieved by starting breastfeeding within the first hour after birth only one third of mothers did so, starting with supplementary liquids and solid food only after
six months more than half of the babies received other liquids before 6 months and introducing supplementary food soon after six months at age 9 months still 23 percent only received breastmilk and
at 12 months still 12.7 percent.
One of the main concerns with respect to Afghanistan’s health system performance remains the very unequal health care provision between urban and rural populations and between provinces. Invariably,
for the majority of Afghanistan’s rural population, service delivery and health outcome indicators are significantly lower than for urban dwellers. And the situation is generally even far worse for the nomadic
Kuchi population.
158
10.1 Introduction
Decades of conflict had a devastating effect on the health system of Afghanistan. At the time of the overthrow of the Taliban regime in 2001, the country recorded some of the world’s worst health
statistics, including estimated infant mortality rates of 165 per thousand live births, under-five mortality of more than 250 per thousand live births and maternal mortality of 1,600 per 100 thousand live births
MoPH 2005. More than one-third of health facilities were severely damaged and the rest failed to meet WHO standards Ministry of Health 2002. In addition, many health professionals had fled the country
and the remaining lacked good clinical training and were severely underrepresented in rural areas. Since then, the Ministry of Public Health MoPH has coordinated the efforts to rebuild the health
system. A strategy to deliver a Basic Package of Health Services BPHS was developed in 2002 and updated in 2005 and 2010, with the aim to provide a core service delivery package in all primary health
care facilities, addressing the principal health problems of the population, especially the most vulnerable groups
– women and children – and the rural population Ministry of Health 2003, MoPH 2005, MoPH 2010. Previous NRVAs and other health surveys showed that
many of Afghanistan’s main health indicators are rapidly improving, although they remain low by international standards. Other health-
related indicators show mixed results: the food security situation in the country remains fragile see chapter 9, but significant advance has been achieved with respect to access to safe drinking water see
chapter 10 and to a lesser extent access to improved sanitation chapter 12. ALCS 2013-14, as its preceding NRVAs, provides information about specific health indicators. Previous
survey rounds covered maternal and child health, access to health facilities, health care expenditure and use of health care providers. In line with the principle of rotating modules in successive surveys, the
present ALCS focused on maternal health section 10.3, breastfeeding 10.4 and access to health facilities 10.2. The next ALCS will again collect data on health care expenditure and disability, next
to some basic information about maternal and child health, family planning and health care access. In addition, the 2015 DHS is expected to provide detailed health information in 2016.
10.2 Access to health services and care-seeking behaviour
