Access to health services and care-seeking behaviour

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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

10.2.1 Travel time, travel costs and staff availability Access to health services is a multi-dimensional concept. It not only relates 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 specific household members, such as children and women the demand-side barriers to access health services. As the previous NRVAs, the ALCS 2013-14 Shura questionnaire provides information about travel time and travel costs required to reach health facilities, as well as information about gender-specific availability of health care staff. These figures should be treated with care because of high non-response rates, as well as the possibl e respondents’ inability to identify the correct type of health care provider and position of health care staff. Distance and costs to reach a health facility can be primary reasons for low use of health care, especially in remote areas. Thus, the 2006 Afghanistan Health Survey AHS suggested that – after the absence of urgency for seeking health care – the most important reason for not seeking care was distance 27 percent and the fourth-most important reason mentioned was transport costs 11 percent. In line with 159 this, male and female Shuras responses to the successive rounds of NRVA invariantly mentioned improved access to health facilities among the top priorities. Table 10.1 panel a gives the percentage of population that is able to reach different types of health facilities within a specified time by any means of transport. It is evident that the urban population has almost universal access to health care of any type within two hours. For rural populations – including Kuchi – access time is less favourable: only around three-quarters can reach a referral hospital or a private clinic within two hours, but close to nine in ten has access to a health post or a public clinic within this time. Compared to NRVA 2011-12, the situation for rural populations seems to have improved with regard to access to public and private clinics both around 83 percent then, but not so with regard to health posts and district or provincial hospitals. However, a major improvement has occurred since 2006, when only 60 percent of the total population – including urban residents – had access to any health facility MoPH 2007. In terms of travel costs to reach different health providers, rural Afghans are much more disadvantaged compared with urban dwellers. They typically pay around nine times as much for a one-way trip to a health facility, on average around 350 Afs per person to a referral hospital or a private clinic, around 185 Afs to a public clinic or a private pharmacy and somewhat less to the nearest health post Table 10.1, panel b. The median travel costs – the costs level below and above which half of rural households has to pay – are usually much less than the average costs. This indicates that there is a large variation in travel costs for rural dwellers, some of whom have to pay large sums to reach health care. Among the modalities considered in the survey, the time to reach a health care provider and the costs involved are by far the most important reasons for women not to use health care services. For 36 percent of women who were in need of health care, the distance to the provider was the main reason not to seek care and for 52 percent the costs were the main reason see also section 10.2.2. Since women usually have to be accompanied by a male family member, the cost for their travel to a health centre is often even more than that for a male patient, making access to health care for women in many cases prohibitively expensive. In the gender-sensitive context of Afghanistan, another impeding factor to seek health care is the absence of same-sex health care staff. Results from the ALCS 2013-14 show that within the public health system only higher up in the referral system and in urban areas any presence of female staff reaches levels close to full coverage Table 10.2 . For example, in rural areas only 43 percent of the population can consult a female doctor in a public clinic and for 28 percent no female midwife is available there. 160 Table 10.1: Population, by residence, and by a travel time to health facilities in percentages and b one-way travel costs to health facilities in Afs a a. Travel time b. Travel costs Type of health facility, Urban Rural b National Type of health facility, Urban Rural b National residence travel cost a. Health post a. Health post Less than 2 hours n.a. 89.7 89.7 Mean n.a. 127 102 2 to 6 hours n.a. 2.8 2.8 Median n.a. 40 20 6 hours or more n.a. 7.5 7.5 b. Public clinic b. Public clinic Less than 2 hours 100.0 88.2 89.9 Mean 23 187 143 2 to 6 hours 0.0 6.9 5.9 Median 10 70 40 6 hours or more 0.0 4.9 4.1 c. DistrictProvincial hospital c. DistrictProvincial hospital Less than 2 hours 98.9 76.9 80.1 Mean 45 354 277 2 to 6 hours 1.1 18.0 15.6 Median 20 150 100 6 hours or more 0.0 5.1 4.3 d. Private clinic d. Private clinic Less than 2 hours 98.5 72.6 77.0 Mean 37 348 258 2 to 6 hours 1.5 19.1 16.1 Median 10 150 80 6 hours or more 0.0 8.3 6.9 e. Private pharmacy e. Private pharmacy Less than 2 hours 100.0 85.0 87.4 Mean 12 183 135 2 to 6 hours 0.0 9.2 7.8 Median 10 60 30 6 hours or more 0.0 5.8 4.9 a Figures between brackets are considered less reliable, since these are based on variables with more than 20 percent missing values. b Including Kuchi 161 Table 10.2: Population, by residence, and by presence of different staff types in different health facilities in percentages a Health care provider, Urban Rural b National staff type a. Health post Female CHW n.a. 40.3 45.4 Male CHW n.a. 71.1 72.2 b. Public clinic Female doctor 89.9 43.3 55.5 Female nurse 93.3 54.8 64.7 Female midwife 85.9 72.1 75.4 Male doctor 93.2 76.8 80.9 Male nurse 88.0 73.2 76.7 c. Districtprovincial hospital Female doctor 99.6 86.3 89.8 Female nurse 99.6 85.7 89.3 Female midwife 99.6 91.1 93.3 Male doctor 99.6 96.9 97.6 Male nurse 98.8 95.0 96.0 d. Private clinic Female doctor 94.3 71.9 78.2 Female nurse 94.1 67.7 75.2 Female midwife 96.5 73.3 79.9 Male doctor 99.2 86.9 90.4 Male nurse 98.2 80.4 85.4 e. Private pharmacy Female CHW 59.2 27.3 36.0 Male CHW 86.7 89.2 88.6 a Figures between brackets are considered less reliable, since these are based on variables with more than 20 percent missing values. b Including Kuchi Despite the generally low levels of female staff, compared to the NRVA 2007-08 their availability has increased. Nationally, female public-clinic staff doctors, nurses and midwives increased with 20 percent or more in the intervening period, and the availability of female staff in private clinics improved even more: midwives with 25 percent, doctors with 31 percent and nurses with 39 percent Figure 10.1 . It is worth noticing that the addition of public female staff except for midwives concentrated in urban areas, whereas by far the largest impact of enhancing the presence of private female staff occurred in rural areas. The increase of female community health workers in health posts between 2007-08 and 2013-14 is estimated at 48 percent data not shown here. 162 Figure 10.1: Increase of female staff in a public and b private clinics since 2007-08, by residence, and by staff type in percentages a a. Public clinics b. Private clinics a Results are considered less reliable, since these are based on variables with more than 20 percent missing values. 10.2.2 Care-seeking behaviour The ALCS 2013-14 had a few questions on whether the female respondent had been sick or injured during the last 30 days before the survey, and what was her subsequent care-seeking behaviour. No less than 43.3 percent of all women 14 years and older responded that they had been sick or injured. Kuchi women indicated most frequently that they had been sick or injured. Almost half of Kuchi women reported they had a medical problem 48.2 percent, against 40.4 percent in urban and 44.2 percent in rural areas. Figure 10.2 depicts the age-specific percentages of women who reported to have been sick or injured during the month before the survey, by five-year age group and whether they had sought treatment or not. Incidence of disease or injury is – not surprisingly – highest among the older group of women. Among all persons 70 plus together, 62.0 percent reported they had been sick or injured: 47.2 percent had sought treatment for their illness and 14.8 percent did not. Even at age 14, one in five girls reported to have been sick. Above age 35, in none of the five-year age groups is the incidence of disease lower than 50 percent. The green line in Figure 10.2 shows the percentage of all women who were sick or injured that sought medical care. In general, among all those who had been sick or injured, 25.8 percent had not sought medical treatment. Typically, between 70 and 80 percent of women seek care when ill, irrespective of age. The percentage of women seeking treatment for illness or injury is about the same between urban and rural areas 75.2 against 74.3 percent. Kuchi women seek treatment a bit less frequently compared to the other groups 68.0 percent. 22 13 24 21 16 23 16 20 21 5 10 15 20 25 30 35 40 45 50 Urban Rural National P er cen tag e Doctor Nurse Midwife 2 39 31 12 45 39 6 28 25 5 10 15 20 25 30 35 40 45 50 Urban Rural National P er ce n tag e Doctor Nurse Midwife 163 Figure 10.2: Women 14 years and older who had been sick or injured during the month before the survey, by age, and by treatment sought in percentages; also women who sought help among sick or injured women, by age in percentages The ALCS 2013-14 also asked for the first and second most important reason why no medical attention was sought. For those why did answer the questions, the reasons why no treatment was sought are presented in Tables 10.3a and 10.3b for urban, rural and Kuchi population groups. 51 First, 23.0 percent of women who did not seek care indicated that the health problem was not serious enough to seek help. This percentage was much higher in urban areas 36.0 percent than in rural areas and among Kuchi women. Consequently, the complementary 77.0 percent of the 25.8 percent ill or injured women who did not seek medical support – some 20 percent of ill or injured women, around 650 thousand women every month – had an unmet need for medical care. For rural women, distance to a health facility is about as important a reason not to seek care as the costs involved around 35 percent. As obviously distance is not a main obstacle in urban areas see also Table 10.1, for urban women the consideration of costs involved in health care becomes the most important reason why they did not get medical attention; 55.3 percent of them indicated this as the first reason. The most important reason for Kuchi women not to seek care is the physical distance to the health facility: 47.8 percent of them indicated medical help is just too far away. Overall, for 39.4 percent of women expenses for treatment, travel and other health-related costs are the first cause to remain untreated when they have health problems, whereas distance is the main reason for 27.9 percent. When zooming in on those women for whom their ill-health condition was sufficient reason to want medical attention, these figures become 36 and 51 percent. In addition, costs and distance were also mentioned 51 Unfortunately, these health questions were not very well answered and no answer was obtained in 37 percent of all cases. 15 16 27 32 36 40 41 45 46 45 48 47 41 61 56 46 6 7 9 12 13 14 14 12 14 15 15 13 16 15 10 14 10 20 30 40 50 60 70 80 90 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85+ P er ce n tag e Age Sick or injured sought care Sick or injured did not seek care 164 as the second most important reason for not using health care, for 15.3 and 17.5 percent of the women who did not seek support Table 10.3b. Table 10.3: Women 14 years and older who were ill or injured during the period of 30 days before the survey and did not seek medical attention, by place of residence, and by a main and b second reason why not seeking health care in percentages a. Main reason Total Urban Rural Kuchi Total 100.0 100.0 100.0 100.0 No neednot serious 23.0 36.1 19.1 16.3 Too expensive 39.4 55.3 34.8 29.6 Too far 27.9 2.8 34.6 47.8 No one to accompany 2.3 2.2 2.5 0.5 Security concern 2.0 0.2 2.6 1.8 No female medical personnel 1.8 0.6 2.3 1.0 Traditional constrain 1.3 0.2 1.7 0.0 Husband or family did not allow 0.9 0.6 1.1 0.0 Other 1.4 2.1 1.1 2.9 b. Second reason Total Urban Rural Kuchi Total 100.0 100.0 100.0 100.0 No neednot serious 2.6 0.9 3.3 1.8 Too expensive 15.3 4.8 18.3 20.9 Too far 17.5 8.6 20.6 15.4 No one to accompany 6.0 3.2 7.1 3.3 Security concern 4.5 0.2 5.9 5.2 No female medical personnel 2.2 0.7 2.6 3.3 Traditional constrain 1.1 0.3 1.0 6.0 Husband or family did not allow 1.7 0.5 2.2 2.0 Other 3.6 2.3 4.2 1.8 No second reason 45.5 78.5 34.8 40.2 Reasons for not seeking medical care that are connected to deprivation of women are ‘no female medical staff’, ‘no one to accompany’, ‘husband or family did not allow’ and ‘traditional constraints’. Of these categories, ‘no one to accompany’ is the most important with 2.3 percent as the first reason and 6.0 percent as the second reason. These results clearly show that poverty and geographical isolation are much more important reasons than gender deprivation to explain why women often do not get the medical attention they need when they are sick or injured. These results confirm the findings of the NRVA 2007-08 and AHS 2006, where expenses and distance were also found to be the major constraints for women to use health services. 165

10.3 Maternal health