Educational attainment - Household shocks and community preferences 109

Health 73 8 Health SUMMARY. The NRVA analysis paints a stark picture of the present performance of Afghanistan’s health sector and its implications for the health status of the population. On most internationally comparable health indicators, Afghanistan is among the most poorly performing countries. Decades of conlict and social conservatism have left a health structure that is particularly adverse to the reproductive health needs of women. The results are relected in the NRVA indings of poor accessibility of health facilities, low contraceptive prevalence, continuous high fertility, and low levels of antenatal care and skilled birth attendance. It was also found that, invariantly, improvement of health facilities ranked among the top priorities for community development, regardless of gender perspective. Despite its very weak state, the health system is now experiencing reconstruction and delivering some results. Although caution for methodological discrepancies is warranted, comparison with previous surveys suggest that use of skilled birth attendance has improved from 16 percent in 2005 to 24 percent in the 2007- 08 period of the NRVA. In addition, the overall contraceptive prevalence increased from 10 percent in 2003 to 23 percent, and a current total fertility rate of 6.3 is found to be nearly one live birth below the fertility level experienced by women aged 40-49. Also, a declining trend was observed for the share of women marrying before age 20, which exposes fewer to the risk of early pregnancy complications. With regard to child health care, improvements seem to have been made, with the notable exception of measles immunization. For the vaccinations included in the Expanded Program on Immunization EPI – BCG against tuberculosis, OPV3 against polio, DTP3 against diphtheria, pertussis and tetanus, and Measles – the estimated immunization rates of the children aged 12-23 months were, respectively 74, 71, 43 and 56 percent. Full immunization is only received by 37 percent of the children, whereas 15 percent have never been vaccinated. Immunization against neonatal tetanus was received by only 33 percent of eligible women. Furthermore, 69 percent of children aged 6-59 months received vitamin-A supplements against infections and 61 percent of households used iodized salt, which helps to prevent goiter and brain damage in children. Finally, with a prevalence of 78 percent, exclusive breastfeeding of children aged 0-6 months seems to be relatively high. However, when information about additional liquids in the irst days is included, the overall exclusive breastfeeding rate drops to only 35 percent. The NRVA reported 406 thousand disabled in Afghanistan, implying a disability prevalence of 1.6 percent. The prevalence rate increases with age, adding to the vulnerable position of the elderly. However, younger disabled persons also face negative consequences: school attendance of disabled children of primary school age and labour force participation of people of working age are only half of that of their non-disabled counterparts.

8.1 Introduction

The health system of Afghanistan is recovering from a collapse in the recent decades of conflict. Many of the country’s main health outcome indicators – although improving – remain at the very bottom of the international rankings. The poor general health conditions in Afghanistan are directly related to many factors such as nutrition, access to safe drinking water and adequate sanitation. Yet one of the main causes for these poor health outcomes not being overcome is the inadequate availability, access and quality of health care services. The 20078 NRVA covered several issues related to health. Other parts of this report deal with fertility and mortality Section 3.4, and access to drinking water and sanitation Section 9.3.1. This chapter specifically focuses on aspects of access to health care Section 8.2, child health – in particular child immunization and breastfeeding practices Section 8.3, reproductive health Section 8.4 and disability Section 8.5. Information on the latter subjects directly relate to components of the Basic Package of Health Services BPHS in Afghanistan: maternal and newborn health, immunization and disability.

8.2 Access to health services

Access to health services is a multi-dimensional concept. It does not only relate to the physical distance to health facilities or the travel time involved, but also involves the costs of travel and services, as well as opportunity costs, cultural responsiveness to clients’ needs, mobility of women, and even the ‘value’ attached to the health and survival of