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9 HEALTH
SUMMARY.
The NRVA 2011-12 conirms the image of a recovering health system in Afghanistan in the past decade, 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 impede progress for many components of maternal and child
health, signiicant improvement is evident from successive surveys in the post-Taliban period. In terms of time required to reach the nearest health facility, access to these facilities has improved
signiicantly with the implementation of outreach programmes of the Ministry of Public Health and the distribution of private health facilities across the country. However, cultural responsiveness
of the health sector – for instance in terms of provision of female health care providers – remains an important obstacle for the effective use of health care, especially by women. In addition, costs for
health services and treatment are prohibitive for many households, in particular for poor households.
The 2011-12 round of NRVA collected limited information about child health. The information indicates mixed results with regard to vitamin A supplementation, prevalence
of acute respiratory diseases and Tetanus Toxoid Injection TT coverage. In addition, the proportion of children oficially registered at birth is still small: 35 percent.
Perhaps the most consistent and impressive improvements are observed for maternal health indicators. The proportions of women served by skilled ante-natal care providers and skilled
birth attendants, and the proportion delivering in institutional health facilities have increased
dramatically in the last decade and reached levels of 51, 40 and 36 percent respectively. One of the main concerns with respect to Afghanistan’s health system performance is the very unequal
health care provision between urban and rural populations. Invariably, for the majority of Afghanistan’s
rural population service delivery and health outcome indicators are signiicantly lower than for urban dwellers. And the situation is generally even far worse for the nomadic Kuchi population.
9.1 Introduction
The health system of Afghanistan is recovering from a collapse in the recent decades of conlict, especially after the adoption of new health policies and a strategy of delivering a basic package of health services since 2005 MoPH 2005.
Although remaining low in international comparison, many of Afghanistan’s main health indicators are rapidly improving. Whereas the food security situation in the country remains fragile see chapter 7 and adequate sanitation remains
poorly available, signiicant advance has been achieved with respect to access to safe drinking water see chapter 10. Other progress has been made with regard to the availability, access and quality of health care services. NRVA 2011-12
provides information about several of these health components, as well as actual health-care use.
9.2 Access to health services
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 speciic household members, such as children and women. The NRVA 2011-12 provides information about travel time and travel
costs required to reach health facilities, as well as information about gender-speciic availability of health care staff, out- of-pocket expenditure on health and actual use of health care providers.
9.2.1 Distance to nearest health facility and costs to reach it
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 this, male and female Shuras responses to the successive
rounds of NRVA invariantly mentioned improved access to health facilities among the top priorities see section 11.4 of this report. It should be expected that given the expansion of Afghanistan’s health care system the importance of these
reasons will have been reduced. The text box on access to health care below provides information about travel time to health facilities and costs involved, as well as staff availability in health facilities. However, due to low response rates,
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this information should not be interpreted as oficial statistics on health care access.
Access to health care
Table 9.1, panel a gives the present percentage of population that is able to reach different types of health facilities within a speciied time by any means of transport. It is evident that the urban population has virtually universal access to health care of any type within two
hours. For rural and Kuchi populations access time is less favourable, but around nine in ten of the non-urban population can reach the nearest health facility within two hours. The corresponding overall igure reported in the 2006 Afghanistan Health Survey AHS was only
60 percent.
Table 9.1: Access characteristics of the nearest health facility for different health facilities, by residencea a. Population, by minimum travel time
b. Mean and median one-way travel cost to nearest health facility in percentages
per person by private transport in Afghanis
Type of health facility, residence Less than
2 hours 2 to 6
hours More
than 6 hours
Type of health facility, residence Mean
Median
a. Health post a. Health post
Urban n.a.
n.a. n.a.
Urban n.a.
n.a. Rural
88.4 8.8
2.8 Rural
208 100
Kuchi 89.5
5.1 5.4
Kuchi 470
250 National
91.2 6.4
2.3 National
176 100
b. Public clinic b. Public clinic
Urban 99.4
0.0 0.6
Urban 154
100 Rural
82.7 14.2
3.1 Rural
320 140
Kuchi 89.7
10.3 0.0
Kuchi 309
150 National
86.9 10.7
2.4 National
278 120
c. District or provincial hospital c. District or provincial hospital
Urban 99.3
0.7 0.0
Urban 141
100 Rural
76.4 18.3
5.3 Rural
447 200
Kuchi 74.4
10.8 14.8
Kuchi 413
300 National
81.7 13.6
4.6 National
368 150
d. Private doctor or clinic d. Private doctor or clinic
Urban 100.0
0.0 0.0
Urban 117
100 Rural
82.9 12.7
4.4 Rural
353 150
Kuchi 76.7
7.5 15.8
Kuchi 366
250 National
86.7 9.3
4.0 National
291 150
a
Figures are indicative only due to high levels of missing values, ranging from 13 percent for public clinics to 33 percent for health posts.
The costs involved to reach a health facility by private transport differ by the type of care provider and by residence Table 9.1, panel b. Half of the population need to pay Afg. 150 or less to reach any type of health facility, but the mean costs are usually twice as high
as the median costs, indicating that for the other half of the population the costs are excessively higher. It should be borne in mind that inancial constraints to health service access are often larger for women, since they are usually required to be accompanied by a male,
doubling any travel costs.
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Availability of health care staff
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 NRVA 2011-12 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 9.2. For example, in rural areas only 52 percent of the population can
consult a female doctor in a public clinic and for 14 percent no midwife is available. However, compared to NRVA 2007-08 the availability of female health care staff has increased signiicantly: the corresponding igures for female doctors and midwives in public clinics at
that time were 38 and 60 percent only CSO 2009. The availability of male health care staff is generally better guaranteed. The igures presented here should be treated with care because of high non-response rates, as well as because of the possible respondents’ inability
to distinguish between different health care staff.
Table 9.2: Availability of health care staff in nearest health facility, by sex of staff, residence, and by health care provider, staff type in percentages
a
Type of health facility, residence Female health care staff
Male health care staff Urban
Rural Kuchi
National Urban
Rural Kuchi
National
a. Health post
Community health worker 91.9
58.3 45.9
67.4 96.8
72.7 93.9
79.6
b. Public clinic
Doctor 96.0
52.3 52.3
63.1 98.9
91.4 100.0
93.6 Nurse
96.0 66.3
60.1 73.3
97.2 88.5
96.8 91.0
Midwife 96.7
85.5 80.4
87.9 na
na na
na
c. District or provincial hospital
Doctor 97.6
87.1 89.0
89.7 100.0
97.9 100.0
98.5 Nurse
99.6 92.0
97.9 94.1
97.7 86.5
96.5 89.8
Midwife 100.0
97.1 98.6
97.9 na
na na
na
d. Private doctor or hospital
Doctor 95.7
72.3 88.9
79.1 98.3
92.0 100.0
94.0 Nurse
95.9 74.5
92.4 80.8
87.2 63.8
96.1 71.6
Midwife 97.9
86.3 92.4
89.5 na
na na
na
a
Figures are indicative only due to high levels of missing values, ranging from 8 percent for district or provincial hospitals to 43 percent for health posts.
9.2.2 Household expenditure on health
The 2006 AHS found that the third-most important reason – with 24 percent of all reasons – for not seeking medical care was the inability to pay the cost of treatment. For many households health expenditure may be prohibitive, especially
if advanced and prolonged treatment or hospitalisation is required. Table 9.3 provides an overview of out-of-pocket expenditure on health in the year preceding the NRVA 2011-12 interviews.
