Visits to health care facilities

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9.2.4 Use of health care providers

There are signiicant differences in the use of health services between in-patient and out-patient care, as well as between urban and rural populations. For hospitalisation public health facilities are the most important care providers, with 19 percent for national hospitals and 58 percent for provincial and other public health facilities in-patient care Table 9.5. Private clinics and private doctors and NGOs serve 17 percent of the population for in-patient care, and 5 percent is treated abroad. For ambulant health services, the irst category is private and NGO care, which provides more than half of the services. In urban areas this is even 69 percent, but also in rural areas it is close to half of out-patient service delivery – almost as important as public health care. All together, the private sector served around 1.5 million people for ambulant care. Table 9.5: Health care seekers in the year before the survey, by residence, and by health care provider A. In thousands B. In percentages Health care provider Urban Rural Kuchi National Urban Rural Kuchi National

a. In-patient health care provider

National hospital 101.7 72.6 4.8 179.1 43.1 11.2 12.5 19.4 Other public health facility 65.2 446.3 26.2 537.6 27.6 68.7 68.3 58.2 Private health facility 54.4 99.7 4.5 158.5 23.0 15.3 11.7 17.2 Health facility abroad 14.9 31.0 2.9 48.8 6.3 4.8 7.6 5.3 Total 236.2 649.5 38.4 924.0 100.0 100.0 100.0 100.0

b. Out-patient health care provider

National hospital 90.5 41.3 1.9 133.7 14.0 2.1 1.4 4.9 Other public health facility 102.4 941.4 64.9 1,108.7 15.8 48.6 47.7 40.7 Private health facility 448.9 942.6 68.8 1,460.3 69.2 48.7 50.5 53.7 Health facility abroad 6.7 10.9 0.6 18.2 1.0 0.6 0.4 0.7 Total 648.6 1,936.2 136.2 2,721.0 100.0 100.0 100.0 100.0

9.3 Child health

Based on the principle of rotating modules, the NRVA 2011-12 round had a restricted battery of questions on child health compared to the 2007-08 round. Only information about Vitamin A supplementation, fever and diarrhea, and acute respiratory illness ARI for children under ive was collected. Reduction of vitamin A deiciency, diarrhea and pneumonia are critical to the achievement of MDG 4, the reduction in under-ive mortality. In addition to this child health information, the number of under-ives with a birth certiicate was recorded.

9.3.1 Birth registration

Although strictly not a health indicator, the percentage of children with a birth certiicate may have health implications in the sense of admission dificulty to health facilities, as well as access to various other services and human rights. The International Convention on the Rights of the Child – to which Afghanistan is a party – states that every child has the right to a name and a nationality, and the right to protection from being deprived of his or her identity. Birth registration is a fundamental means of securing these. NRVA 2011-12 indicated that 35 percent of children under 5 had a birth certiicate 1 Table 9.6, slightly below the share reported by the MICS 2010 37 percent. This would imply that 3 million under-ives are not registered as citizen of Afghanistan. Urban children were more than twice as likely to be registered as rural children 64 compared to 29 percent, and only 16 percent of Kuchi children were registered. 1 Based on verbal report, without having seen the certiicate. 90 HEALTH

9.3.2 Child health indicators

Vitamin A supplementation Vitamin A deiciency is of major public health signiicance in many parts of the world where poverty is extensive and resources are limited. The association between vitamin A deiciency and an increase in childhood prevalence and severity of infectious diseases, blindness and mortality has been well documented. As shown in Table 9.6, the share of children under-ive that received vitamin A supplementation was found to be 60 percent, which is higher than the MICS 2010 igure of 51 percent. The AHS 2006 reported a 77 percent coverage. 2 These results may vary because vitamin A supplementation often coincides with polio or measles campaigns, which occur at speciic intervals. Fever and diarrhea Fever was the second-most reported health problem in the past month for children under-ive in the AHS 2006. In the NRVA 2011-12 a share of 40 percent of under-ives was recorded to have had fever in the last month before the survey. Of these children with fever, 55 percent 22 percent of all under-ives also had diarrhea. Table 9.6: Children under ive years of age, by residence, and by different indicators in percentages Indicator Urban Rural Kuchi National With birth certiicate 63.8 29.5 16.3 35.2 With vitamin A supplementation 75.8 56.4 50.5 59.8 In last month before the interview: With fever 40.1 40.3 39.6 40.2 With fever and diarrhea 20.7 22.8 20.6 22.2 With symptoms of acute respiratory illness 13.4 13.8 13.0 13.7 a Based on verbal report, without having seen the certiicate. Acute respiratory illness Pneumonia is the world number one killer of children under-ive UNICEF and WHO 2006. Undernourished children, particularly those not exclusively breastfed, are at higher risk of developing pneumonia. Similarly, children and infants suffering from other illnesses, such as measles, are more likely to develop pneumonia. Environmental factors, such as living in crowded homes or indoor air pollution, may also have a role to play in increasing children’s susceptibility to pneumonia and its severe consequences. All these factors are particularly present in Afghanistan see sections 10.2.2. According to NRVA 2011-12 out of all children under-ive, 14 percent corresponding to 611 thousand children had symptoms of acute respiratory illness, measured as having been ill with a cough accompanied by short, rapid breathing at any time during the month preceding the interview. Injections against neonatal tetanus People of all ages can get tetanus, but the disease is particularly common and serious in newborn babies. Neonatal tetanus, which is mostly fatal, is particularly common in rural areas where deliveries are mostly done at home without adequate sterile procedures. Tetanus can be prevented through immunization with tetanus-toxoid TT containing vaccines, which is given to women of childbearing age with, either during pregnancy or outside of pregnancy. This protects the mother and – through a transfer of tetanus antibodies to the fetus – also her baby. For full protection, a pregnant woman should receive at least two doses during each pregnancy. If a woman has been vaccinated during a previous pregnancy or during maternal and neonatal tetanus vaccination campaigns, however, she may only require one dose for the current pregnancy. Five doses are considered to provide lifetime protection. 2 MICS and AHS reported for children 6-59 months of age. 91 HEALTH Figure 9.2 presents the percentage of women aged 15-49 with a live birth in the ive years preceding the survey by the number of TT injections received during the last pregnancy. Overall and for pregnancies of rural women, full protection was recorded for just over one-third 35 percent of the women. For urban women the corresponding share was higher, but still close to half 46 percent did not receive the required two injections. Kuchi women are very much deprived of TT coverage, as 84 percent did not receive any injection at all during their last pregnancy. Figure 9.2: Women aged 15-49 with a live birth in the ive years preceding the survey, by residence, and by the number of TT injections received during the last pregnancy in percentages 10 20 30 40 50 60 70 80 90 Urba n Rura l Kuchi Na tiona l 46 57 84 57 12 8 3 9 43 35 13 35 No 1 2 or more

9.4 Maternal health

Reproductive health implies that women have the right of access to appropriate health care services that will enable them to go safely through pregnancy and childbirth and provide couples with the best chance of having a healthy infant. A limited and non-representative survey in 2002 suggested a maternal mortality ratio MMR of at least 1,600 per 100,000 births, which would imply that the life-time risk of women dying to pregnancy-related causes was at least one in nine Bartlett et al. 2005. These igures would rank Afghanistan among the very highest in the world in terms of maternal mortality.

9.4.1 Ante-natal care

Skilled antenatal care ANC services present opportunities for reaching pregnant women with interventions that may be vital to their health and that of their infants. These interventions include medical check-ups, referrals of pregnancies that could result in complicated deliveries, and information about managing pregnancies and deliveries, immunization, breastfeeding and child spacing. Overall, 51 percent of women reported at least one visit to or of skilled ANC providers doctors, nurses or midwives. Use of skilled ANC services during a woman’s last pregnancy in urban and rural areas was, respectively, in 78 and 46 percent of the cases Figure 9.3, panel a. The proportion of women using skilled ANC services was lowest among the Kuchi women 23 percent. Some 49 percent of the women did not receive any care at all 22 percent in urban areas and 54 percent in rural areas. Education was signiicantly associated with skilled antenatal care, and especially the difference between women with no education and primary education is notable: 80 percent of the latter received ante-natal care, whereas only 49 of the former did so. Women with higher education approach universal coverage. Age of mother was also clearly associated with the use of skilled ANC services.