Causes and consequences of disability

Health 90 Figure 8.6 Labour force participation rates and unemployment rates, by disability status, sex

8.6 Conclusions

For various health indicators, the NRVA provided new information to assess the health status in the population and the performance of the health sector of Afghanistan. To the extent that methodological similarities allow, trends can be established by comparing the present results with the findings of the MICS 2003, NDSA 2005, NRVA 2005 and AHS 2006. The overall conclusion of this assessment is that many health indicators are improving, but remain well below desirable levels, and are often abysmal in comparison to levels in other countries. The build-up of health infrastructure and access to health services, especially in rural areas, are badly needed. It is, therefore, not surprising to find that improvement of health facilities invariantly ranks among the top priorities for community development, regardless of gender perspective. Presently, of the large rural majority seeking affordable public health care only about half 54 percent can reach a facility within one hour walking. In remote areas, where motorized transport is required to reach health centers, transport costs play an additional role as barrier to health care access. Women are in a particularly disadvantaged position since they usually cannot travel alone, which doubles out-of-pocket expenditure on transportation. In addition, lack of female staff – only 29 percent of nearest health posts has a female community health worker – feeds the resistance to health center visits by women in need of medical assistance, probably especially if it concerns reproductive health. These factors contribute to the low use of family planning 23 percent overall, 15 percent using modern contraceptive methods, antenatal care 36 percent and skilled birth attendance 24 percent, and denies many women life-saving emergency obstetric care. Early pregnancies, closely spaced births 53 percent of reported birth intervals less than 24 months and bearing many children a TFR of 6.3 further make women pay a high price for giving new life. For almost all indicators, the figures underline the substantial differences that exist between rural, urban and Kuchi populations. Whereas the NRVA analysis paints a harsh reality, it also discovers some hopeful signs of improvement. Section 3.3.2 reported that for successive younger cohorts the share of women marrying before age 20 declined and section 3.4.1 indicated that fertility is, slowly, declining for women aged 40-49 a TFR of over 7 was estimated. The present analysis suggests that the use of contraceptives is rapidly increasing from 10 percent for overall contraceptive use in 2003, that use of antenatal care has grown from 32 percent in 2006, and the use of skilled birth attendance has substantially increased from 15 percent in 2003. If these assessments reflect genuine developments, there is every chance that the latest estimate of the maternal mortality ratio of 1,600 is outdated and requires downward adjustment. A new effort should be undertaken to provide an up-to-date estimate of maternal mortality. This is, however, outside the scope of the NRVA. Also 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 immunization rates of the children aged 12-23 months were, respectively 74, 71, 43 and 56 percent, well above rates found in the 2005 NRVA. However, full immunization is only received by 37 percent of children, whereas 15 percent have never been vaccinated. Immunization against neonatal tetanus was received by only 33 percent of eligible women. Encouragingly, 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 first days is included, the overall exclusive breastfeeding rate drops to only 35 percent. The complementary feeding rate is relatively low at 41 percent. Notwithstanding advances in several areas, cost-effective immunizations and provision of micro-nutrients needs to become more widespread in order to improve the health and survival chances of children. Another strategy to this effect would be information campaigns about breastfeeding and supplementary feeding of young children. A disability prevalence rate of 1.6 percent was found for the Afghan population – 1.9 for males and 1.4 for females – representing over 400 thousand disabled, of which some 188 thousand had multiple disabilities. The prevalence rate increases with age, adding to the vulnerable position of the elderly. However, also younger people may face negative consequences, as demonstrated by strong exclusion effects in education and labour force participation: 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. The situation of the disabled requires more in-depth analysis, for which the NRVA can provide adequate data. In addition, population data collection to be conducted in the future – in particular also including the population census – should seriously consider including the recently developed disability module. Health 91 92 Housing 9 Housing SUMMARY. The housing conditions of the Afghan population can be deined as extremely poor. With regard to public services, only 27 percent of the population has access to safe drinking water, 20 percent is connected to the electric grid and no more than 5 percent has improved sanitation. The lack of basic infrastructure for water and sanitation implies high risks for contracting potentially fatal diseases, and is especially detrimental for the health and survival chances of infants and young children. Community Shuras also assign top priority to the water supply. The lack of electricity prohibits effective spread of information to the general public through mass media, like radio, TV and internet. Use of the latter is virtually absent among the population, whereas use of mobile phones has penetrated into only 6 percent of the population. Health conditions in the household are further impaired by overcrowding in 34 percent of the dwellings, and by the use of solid fuels for cooking 83 percent and heating 98 percent. The breakdown by residence invariantly shows that rural and Kuchi populations are signiicantly disadvantaged compared to the urban population. The magnitude of this observation is further ampliied by the notion that the MDG measure on urban living conditions indicates that 93 percent – 4.4 million people – live in conditions of poverty and physical and environmental deprivation. One component of this indicator is the share of the population that has insecure tenancy, an issue that gains relevance in view of absence and return of refugees and IDPs. It is observed that a large number 44 percent in urban areas, 23 percent overall of households cannot prove the ownership of their dwelling by either inheritance, building the house, formal renting agreements or having a registered deed.

9.1 Introduction

The housing situation of a population is often a direct reflection of their living conditions and socio-economic development. This chapter describes different housing characteristics, including the tenancy status Section 9.2 and various facilities usually related to the housing situation, such as water supply and sanitation, but also available communication and information means section 9.3. Consequently, the chapter also covers several related MDG indicators, including the access to safe drinking water and adequate sanitation.

9.2 Housing ownership and characteristics

9.2.1 Housing type and ownership

The pattern of housing types in Afghanistan is dominated by single-family houses. Of the sedentary population in urban and rural areas this housing type accommodates, respectively, 55 and 76 percent of households Table 9.1. While for rural households the figure is similar to that reported in the 2005 NRVA, the urban figure is lower, down from 63 percent in 2005. The segment of households in urban areas that share a dwelling has considerably increased since 2005, from 22 to 40 percent. Although such a large shift from separate to shared dwellings is difficult to explain, it has possibly to do with increasing pressure on the housing market due to internal population growth and urban in-migration. The latter refers not only to ‘regular’ rural-urban migration, but also to the relatively large in-flows of IDPs and returning refugees see section 3.6.2. The drop of urban households living in temporary shelters or shacks from 7 to 3 percent may be an indication of the recovery of the urban housing stock after the large-scale destruction on the 1990s. Table 9.1 Households, by type of dwelling, and by residence Residence Type of dwelling Single family house Part of a shared house Appartment Tent Temporary sheltershack Other Total Urban 55 40 2 3 100 Rural 76 19 4 1 100 Kuchi 24 4 65 7 100 National 69 22 4 4 1 100