Health Care In Afghanistan Research Articles

Using Mobile Health (mHealth) Applications to Improve Access to Healthcare in Afghanistan

This study investigates the utilization of mobile health (mHealth) applications to improve healthcare access in Afghanistan. The research employs a mixed-methods approach, combining qualitative interviews and quantitative surveys with healthcare providers, patients, technology experts, and health administrators at Sehat Hospital in Kabul. Through thematic analysis of interview data and descriptive and inferential analysis of survey responses, the study explores the current landscape of mHealth applications, including their availability, features, usage patterns, and perceived impact on healthcare delivery and patient outcomes. The findings reveal diverse perceptions among participants regarding the accessibility, relevance, and effectiveness of mHealth interventions in Afghanistan. Challenges related to security, cultural adaptation, and user awareness are identified, alongside opportunities for enhancing the design and implementation of mHealth solutions. The study contributes valuable insights into the potential of mHealth applications to address healthcare disparities and improve patient outcomes in resource-constrained settings like Afghanistan. Recommendations for policymakers, healthcare providers, and technology developers are provided to optimize the use of mHealth technologies and maximize their impact on healthcare delivery. Overall, this research underscores the importance of contextually relevant and user-centered approaches in leveraging technology to advance healthcare access and quality in Afghanistan.

Mental health care in Afghanistan: The need of the hour

Mental health care in Afghanistan: The need of the hour

Calculating the Cost and Financing Needs of the Basic Package of Health Services in Afghanistan: Methods, Experiences, and Results

The Basic Package of Health Services (BPHS) is the basis for primary health care in Afghanistan and should be accessible to all citizens. Most of these health services have been provided by nongovernmental organizations with support from donors. Studies before 2018 found that utilization and quality of services were lower than they should be, partly due to insufficient resources, leading the Ministry of Public Health to conduct a costing study to determine the level of funding required for the BPHS.We expanded and refined that data analysis in this article. The main findings show that the total recurrent expenditure on BPHS interventions in 2018 was US$281 million (US$8.93 per capita)-only 62% of the US$452 million (US$14.34 per capita) required for good quality of care. It also showed that the need for services was probably not fully met by public facilities, with actual utilization less than 50% of the need in some cases. Furthermore, scaling up to entirely meet the need could require 2 to 3 times the resources used in 2018.Following the change of government in 2021, economic problems, food shortages, reductions in donor funding, and other factors have increased the need for public health services while the capacity and quality of those services have deteriorated. Nongovernmental organizations continue to provide the BPHS, which remains the main platform for primary health care services in Afghanistan, and international organizations are working to rebuild and support these health services. But additional donor support is needed. The results of this study provide important information on the cost and financing needs of the BPHS that can be used for advocacy and for financing and planning services. We also describe the methodology, challenges, and solutions that can be helpful to other countries interested in conducting similar analyses.

Efficiency analysis of primary healthcare facilities in Afghanistan

BackgroundAfghanistan’s health system is unique in that primary healthcare is delivered by non-governmental organizations funded by multilateral or bilateral donors, not the government. Given the wide range of implementers providing the basic package of health services, there may be performance differences in service delivery. This study assessed the relative technical efficiency of different levels of primary healthcare services and explored its determinants.MethodData envelopment analysis was used to assess the relative technical efficiency of three levels of primary healthcare facilities (comprehensive, basic, and sub-health centers). The inputs included personnel and capital expenditure, while the outputs were measured by the number of facility visits. Data on inputs and outputs were obtained from national health information databases for 1263 healthcare facilities in 31 provinces. Bivariate analysis was conducted to assess the correlation of various elements with efficiency scores. Regression models were used to identify potential factors associated with efficiency scores at the health facility level.ResultsThe average efficiency score of health facilities was 0.74 when pooling all 1,263 health facilities, with 102 health facilities (8.1%) having efficiency scores of 1 (100% efficient). The lowest quintile of health facilities had an average efficiency score of 0.36, while the highest quintile had a score of 0.96. On average, efficiency scores of comprehensive health centers were higher than basic and sub-health centers by 0.11 and .07, respectively. In addition, the difference between efficiency scores of facilities in the highest and lowest quintiles was highest in facilities that offer fewer services. Thus, they have the largest room for improvement.ConclusionsOur findings show that public health facilities in Afghanistan that provide more comprehensive primary health services use their resources more efficiently and that smaller facilities have more room for improvement. A more integrated delivery model would help improve the efficiency of providing primary healthcare in Afghanistan.

Afghan women and access to health care in the past 25 years.

Afghan women and access to health care in the past 25 years.

Facility-level determinants of quality routine intrapartum care in Afghanistan

BackgroundAlthough there have been notable improvements in availability and utilization of maternal health care in Afghanistan over the last few decades, risk of maternal mortality remains very high. Previous studies have highlighted gaps in quality of emergency obstetric and newborn care practices, however, little is known about the quality of routine intrapartum care at health facilities in Afghanistan.MethodsWe analyzed a subset of data from the 2016 Afghanistan Maternal and Newborn Health Quality of Care Assessment that comprised of observations of labor, delivery and immediate post-partum care, as well as health facility assessments and provider interviews across all accessible public health facilities with an average of five or more births per day in the preceding year (N = 77). Using the Quality of the Process of Intrapartum and Immediate Postpartum Care index, we calculated a quality of care score for each observation. We conducted descriptive and bivariate analyses and built a multivariate linear regression model to identify facility-level factors associated with quality of care scores.ResultsAcross 665 childbirth observations, low quality of care was observed such that no health facility type received an average quality score over 56%. The multivariate regression model indicated that availability of routine labor and delivery supplies, training in respectful maternity care, perceived gender equality for training opportunities, recent supervision, and observation during supervision have positive, statistically significant associations with quality of care.ConclusionsQuality of routine intrapartum care at health facilities in Afghanistan is concerningly low. Our analysis suggests that multi-faceted interventions are needed to address direct and indirect contributors to quality of care including clinical care practices, attention to client experiences during labor and childbirth, and attention to staff welfare and opportunities, including gender equality within the health workforce.

National and subnational estimates of coverage and travel time to emergency obstetric care in Afghanistan: Modeling of spatial accessibility.

In Afghanistan, the risk of maternal death is among the highest in the world, with wide variation across the country. One explanation may be wide geographic disparities in access and use of maternal health care services. This study describes the spatial distribution of public facilities providing maternal health care in Afghanistan, specifically emergency obstetric care (EmOC), and the differences in travel time estimates using different transportation modes from 2010 to 2015at the national and subnational levels. We conducted mapping and spatial analyses to measure the proportion of pregnant women able to access any EmOC health facility within 2h by foot, animal, motor vehicle and a combination of transport modes. In 2015, adequate coverage of active public health facilities within 2h of travel time was 36.6% by foot and 71.2% by a combination of transport modes. We found an 8.3% and 63.2% increase in access to EmOC facilities within 2h of travel time by a combination of transport modes and by foot only, respectively, by 2015. Access to a combination of transportation options such as motor vehicles and animals may benefit pregnant women in reaching health facilities efficiently. Afghanistan made impressive gains in maternal healthcare access; despite these improvements, large disparities remain in geographic access by province and overall access to facilities is still poor.

Contraceptive Methods, Maternal and Neonatal Mortality in Afghanistan: Based on the Interview

Objective: The research is carried out in the framework of the development project “Improving Quality of Medical and Info-technological education in North and East Afghanistan in 2014-2016.” The Afghan midwives were educated about contemporary professional theoretical and practical skills within the training, whereas prior it was necessary to determine the existing knowledge and skills of the target group. It was possible to plan the content quality of the training with the support of the results of current research in accordance with the needs of the target group. The study’s aim is to describe contraceptive methods, maternal and neonatal mortality in Afghanistan and to analyses results of the interviews during professional training for Afghan midwives in Estonia, Tallinn Health Care College. Methods: The research method is qualitative based on semi-structured interviews. The target group comprised nine Afghan midwives from North and East Afghanistan. The questionnaire consisted of questions, which were divided into three themes: contraceptive methods, maternal mortality and neonatal mortality. Results: According to interviews, in Afghanistan, a variety of contraception is available: hormonal oral pills, birth control implants, and hormone injections, intra-uterine contraceptive and male condoms. Abortion is prohibited by law, but it is exercised in disguise. In rural areas, contraception is more difficult to access than in cities. There are several factors hindering the use of contraceptives and family planning in Afghanistan, such as family-related or societal religious standards and values, fear and ignorance of side effects, insufficient counseling skills of the midwives and lack of female doctors also high cost of contraceptives. There are many children in the families in Afghanistan. The birth of a baby boy is preferred because there is a widespread misconception that boys ensure the well-being of the family. Women from urban areas give birth in urban hospitals. Women from rural areas give birth at home, there is a high risk for the onset of complications and professional help is not available. The women are invited to the hospital for the midwife’s postpartum appointment but most women prefer not to go there, which increases the risk for the onset of postpartum complications. Newborn care consists of many different factors, which are hazards to the health of a newborn, such as not using colostrum, washing the newborn and several other inappropriate methods of care. Prematurity, low birth weight, infections etc. are highlighted as causes for neonatal mortality. Healthcare in Afghanistan as a whole is uneven, and needs systematic rearrangements. Midwifery care is not available in rural areas. Training of midwives should be supported and improved at the national level in order to provide even availability and quality of midwifery care. The measures listed help to alleviate problems related to family planning and to reduce the maternal mortality and neonatal mortality rates. Conclusions: Afghan midwives require modern and evidence-based training what is based on accepted guidelines, medical and info-technological education. Tallinn Health Care College will continue to improve medical and info-technological education training of Afghan midwives. The target groups were educated about contemporary professional theoretical and practical skills, which covered pregnancy and delivery period and postpartum period, counseling in reproductive health, includes family planning, newborn care, women’s rights and digital technology.

Insecurity and lack of funds hamper progress on Afghan health service

Ambitious Afghan Government plans to provide basic health-care services to 25 million Afghan people who have one of the lowest health standards in the world are being hampered by a lack of funds and mounting insecurity, government and humanitarian officials said. Abdullah Sherzai, Deputy Minister of Public Health, told the Bulletin that his ministry was still waiting for almost half the funds needed for this year's budget alone. Donors, like USAID and The World Bank, have approved the Afghan Government plan. But some donors are not providing enough funds for this, preferring more visible projects with more immediate results, such as building a big hospital in Kabul and other cities, officials say. Out of a total US$ 200 million we budgeted for the provision of the Basic Package of Health Services (BPHS) this year, only 50-60% of the money has been disbursed, Mr Sherzai said, speaking from Kabul in August. The Basic Package initiative, developed by the Afghan Government in cooperation with nongovernmental organizations (NGOs), and United Nations agencies including WHO, aims to provide a standardized set of basic health services at primary level to improve the health status of Afghans. Maternal mortality is alarmingly high, with about 1700 women dying for every 100 000 live births because of complications that could easily be prevented. The situation is worse in remote areas. The country has one of the highest infant mortality rates in the world--with 165 deaths per 1000 live births. One in four children die before their fifth birthday. Life expectancy at birth is only 46 years. Most Afghans, particularly those in rural areas, do not have access to health care because more than two decades of war have destroyed or damaged the majority of health facilities and educational institutions, and many health-care workers have been displaced or killed. Dr Khalid Shibib of WHO's Emergency and Humanitarian Action Department said that although access to health care in Afghanistan has been improving slowly, it is not very different to many other underdeveloped countries. A serious problem is a lack of mental health resources and a shortage of professional mental health care workers. A team of researchers warned in August that the prevalence of mental disorders in Afghanistan was alarming and required immediate attention by donors and policy-makers (JAMA 2004;292:575-93). With decades of war, the people of Afghanistan have gone through uniquely traumatic experiences that have affected their mental health, said Dr Barbara Lopes Cardozo, a psychiatrist at the Centers for Disease Control and Prevention in Atlanta. …

Patients struggle to access effective health care due to ongoing violence, distance, costs and health service performance in Afghanistan.

BackgroundThe Afghan population suffers from a long standing armed conflict. We investigated patients’ experiences of their access to and use of the health services.MethodsData were collected in four clinics from different provinces. Mixed methods were applied. The questions focused on access obstacles during the current health problem and health seeking behaviour during a previous illness episode of a household member.ResultsTo access the health facilities 71.8% (545/759) of patients experienced obstacles. The combination of long distances, high costs and the conflict deprived people of life-saving healthcare. The closest public clinics were underused due to perceptions regarding their lack of availability or quality of staff, services or medicines. For one in five people, a lack of access to health care had resulted in death among family members or close friends within the last year.ConclusionsViolence continues to affect daily life and access to healthcare in Afghanistan. Moreover, healthcare provision is not adequately geared to meet medical and emergency needs. Impartial healthcare tailored to the context will be vital to increase access to basic and life-saving healthcare.

Development of the community midwifery education initiative and its influence on women's health and empowerment in Afghanistan: a case study.

BackgroundPolitical transition in Afghanistan enabled reconstruction of the destroyed health system. Maternal health was prioritised due to political will and historically high mortality. However, severe shortages of skilled birth attendants - particularly in rural areas - hampered safe motherhood initiatives. The Community Midwifery Education (CME) programme began training rural midwives in 2002, scaling-up nationally in 2005.MethodsThis case study analyses CME development and implementation to help determine successes and challenges. Data were collected through documentary review and key informant interviews. Content analysis was informed by Walt and Gilson’s policy triangle framework.ResultsThe CME programme has contributed to consistently positive indicators, including up to a 1273/100,000 reduction in maternal mortality ratios, up to a 28% increase in skilled deliveries, and a six-fold increase in qualified midwives since 2002. Begun as a small pilot, CME has gained support of international donors, the Afghan government, and civil society.ConclusionCME is considered by stakeholders to be a positive model for promoting women’s education, employment, and health. However, its future is threatened by insecurity, corruption, lack of regulation, and funding uncertainties. Strategic planning and resource mobilisation are required for it to achieve its potential of transforming maternal healthcare in Afghanistan.

Telemedicine in north Afghanistan connecting remote area with international medical centres

Background Afghanistan is lacking of human resources in all medical fields due to 30 years of military conflict. Rural and remote areas, in particular, have poor medical health care and standards. There are only three major hospitals in the northern provinces providing medical service for more than 2 million inhabitants on a low medical level, caused mainly by poor diagnostic facilities in the pathology, radiology, dermatology and laboratory sections. Therefore the GIZ (Gesellschaft fuer Internationale Zusammenar-beit) and the KfW (Kreditanstalt fuer Wiederaufbau) launched a telemedicine project starting off with telepathology in 2010 and expanding to teleradiology in 2011, to teledermatology in a second step in 2013, and recently covering also teletraumatology and telepsychiatry. The project started in Mazar E Sharif and was extended to Kunduz and Taloqan. All peripheral stations have been connected via IPATH Basel with international experts rep. centres to get valid second opinions of high diagnostic accuracy. Material and methods More than 1600 cases have been submitted via the Internet to European pathologists and cytologists, in addition to 100 radiological and 10 dermatological cases to experts in the respective fields. Out of this material 300 of the latest cases of pathology and cytology were analysed with respect to: 1) information quality: number and quality of images, additional macro and X-ray images, clinical information and the primary diagnosis; 2) diagnostic accuracy of the experts classifying in secure, suggestive and non-diagnostic assessment; 3) diagnostic accuracy of the inexperienced clients measuring the concordance between client sender and expert; 4) radiology and dermatology cases were not analysed in this study. Results and conclusion The restrospective analysis showed: 1) there was a predominance of cytologal cases of more than 50% (FNA) over histologal cases; 2) most cases were dealing with GI tract (oesophageal lesions) followed by breast tumours (cancer) and lymph node lesions (TB); 3) the diagnostic assessment of the experts was secure in 70%, suggestive in 20% and no diagnosis was given in 10% of the cases due to insufficient information; 4) diagnostic total concordance was seen in 55%, acceptable concordance in 10% and discrepancy in 35% of the cases. The authors conclude: 1) telepathology and telecytology are based on simple techniques; 2) structured and optimal information is required to achieve high diagnostic accuracy of the experts; 3) telepathology and telecytology are optimal tools to increase diagnostic and therapeutic quality in medical health care in Afghanistan. Afghanistan is lacking of human resources in all medical fields due to 30 years of military conflict. Rural and remote areas, in particular, have poor medical health care and standards. There are only three major hospitals in the northern provinces providing medical service for more than 2 million inhabitants on a low medical level, caused mainly by poor diagnostic facilities in the pathology, radiology, dermatology and laboratory sections. Therefore the GIZ (Gesellschaft fuer Internationale Zusammenar-beit) and the KfW (Kreditanstalt fuer Wiederaufbau) launched a telemedicine project starting off with telepathology in 2010 and expanding to teleradiology in 2011, to teledermatology in a second step in 2013, and recently covering also teletraumatology and telepsychiatry. The project started in Mazar E Sharif and was extended to Kunduz and Taloqan. All peripheral stations have been connected via IPATH Basel with international experts rep. centres to get valid second opinions of high diagnostic accuracy. More than 1600 cases have been submitted via the Internet to European pathologists and cytologists, in addition to 100 radiological and 10 dermatological cases to experts in the respective fields. Out of this material 300 of the latest cases of pathology and cytology were analysed with respect to: 1) information quality: number and quality of images, additional macro and X-ray images, clinical information and the primary diagnosis; 2) diagnostic accuracy of the experts classifying in secure, suggestive and non-diagnostic assessment; 3) diagnostic accuracy of the inexperienced clients measuring the concordance between client sender and expert; 4) radiology and dermatology cases were not analysed in this study. The restrospective analysis showed: 1) there was a predominance of cytologal cases of more than 50% (FNA) over histologal cases; 2) most cases were dealing with GI tract (oesophageal lesions) followed by breast tumours (cancer) and lymph node lesions (TB); 3) the diagnostic assessment of the experts was secure in 70%, suggestive in 20% and no diagnosis was given in 10% of the cases due to insufficient information; 4) diagnostic total concordance was seen in 55%, acceptable concordance in 10% and discrepancy in 35% of the cases. The authors conclude: 1) telepathology and telecytology are based on simple techniques; 2) structured and optimal information is required to achieve high diagnostic accuracy of the experts; 3) telepathology and telecytology are optimal tools to increase diagnostic and therapeutic quality in medical health care in Afghanistan.

Report: addressing maternal and child health in post-conflict Afghanistan: the way forward

Afghanistan's maternal and child mortality rates are among the highest in the world. The country faces challenges to meet the Millennium Development Goals set for 2015 which can be attributed to multiple causes related to accessibility, affordability and availability of health-care services. This report addresses the challenges in strengthening maternal and child health care in Afghanistan, as well discussing the areas to be prioritized. In order to ensure sound maternal and child health care in Afghanistan, policy-makers must prioritize monitoring and surveillance systems, integrating maternal and child health care with rights-based family planning methods, building human resources, offering incentives (such as the provision of a conditional cash transfer to women) and promoting action-oriented, community-based interventions. On a wider scale, the focus must be to improve the health infrastructure, organizing international collaboration and expanding sources of funding.

Midwifery retention and coverage and impact on service utilisation in Afghanistan

Objectiveto measure the rate of and determine factors associated with community midwifery education (CME) graduate retention in public sector health care in Afghanistan. Designcross-sectional. Settingperformed in public health facilities of 11 Afghan provinces purposively selected by geographic location and security conditions, between October 2011 and April 2012. Facilities were selected by one of two criteria: either a registered deployment site for a CME graduate or randomly selected through population-proportionate sampling. Participantsfacility managers and midwives employed in public facilities at the time of data collection. Measurementsthree quantitative instruments were used: a facility checklist assessed staffing and service volume, and two separate questionnaires for midwives and facility managers, which measured employment duration and perceived barriers to midwife retention. Findingsat 456 surveyed facilities, 570 midwives were interviewed. Overall, 61.3% (n=209/341) of CME graduates deployed in surveyed provinces were working in public sector facilities, whereas 36.8% were working at their assigned site. Facilities without midwife staff had lower average monthly volumes of antenatal care visits (14.6 (SD±22.7) versus 71.5 (SD±72.5)), family planning visits (10.4 (SD+13.9) versus 56.8 (SD+85.0)), or facility-based deliveries (0.55 (SD±2.2) versus 15.7 (SD±18.7)). Perceived reasons for leaving employment were insecurity (civil unrest/armed conflict) (46.4%), family disagreement (28.1%), increased workload without compensation (9.9%), and lack of appropriate housing (7.8%). Key conclusionsCME graduate retention in public sector positions was relatively low and significantly impacted by insecurity and cultural issues related to women working outside the home. Implications for practiceculturally appropriate measures are needed to attract and retain skilled female health care providers for rural public facilities in Afghanistan and similar settings. Advocacy to encourage family and community support for midwives working in rural facilities and providing amenities such as housing, education for children, and employment for the accompanying male family member are measures most likely to improve midwife retention.

Public health care in Afghanistan: An investigation in suboptimal utilization of facilities

Afghanistan has made strides in increasing access to health care services since 2001 however it is still battling with poor utilization of services. In order to enhance demand for services a study was conducted to explore answers to the questions on knowledge, attitude and practices of communities in relation to healthcare services. The study design was cross-sectional qualitative spanning in six provinces representing geographical and ethno cultural regions of the country. In each of the six provinces, two districts were selected through mixed sampling technique representing urban-rural population. A total of 48 villages were selected in twelve districts. The study was conducted from September 2009 to March 2010. The study highlights poor heath seeking behavior associated with physical accessibility including high cost of transportation, socio-cultural barriers for women, awareness and trust for public health facilities. The system based issues adds to prevailing access related barriers such as privacy, efficiency and availability within health facilities; lack of female physicians and, aspects of behavior and attitude, and governance issues.

Rough roads to better care

Mohammad Qasim, a portly man from southern Afghanistan, has criss-crossed some of the most dangerous terrain on earth in search of a cure for his haemorrhoids. Sitting on a hospital bed in Kabul, the Afghan capital, he explained how he had travelled down dirt roads dotted with homemade mines to see doctors capable of treating his condition. It's a big problem for me, he says. A lot of people with this problem haven't been cured and now they're in big pain. am trying to solve it before it gets that bad. At clinic after clinic Qasim says doctors prescribed pills that had no effect, or left him feeling worse. From his home of Gereshk he went south to the provincial capital of Lashkar Gah. From there he made the difficult 500 kilometre overland journey to Kabul, and back again. He is now in Kabul a second time, about to undergo surgery after various medications have failed to ease the pain. I took a lot of pills, he says. Now I'm just trying to be careful with my diet. He reckons he has spent around US$ 200 on tablets, doctor's fees and transport--the equivalent of three months' pay. lengths to which Qasim has gone may seem extreme, but many Afghans venture back and forth across their ravaged country to seek medical attention. In the same hospital in Kabul was a man from the suburbs of the northern province of Takhar, who had made the day-and-a-half journey across the backbone of the Hindu Kush to get orthopaedic treatment. [ILLUSTRATION OMITTED] Another patient had spent the past month travelling between Kabul and his home in Ghazni province--along one of the country's most dangerous highways--for an operation, and then further care after complications set in. In the southern city of Kandahar, one person interviewed derided the regional hospital as a place you go to if you want to die. 60% of patients in the Pakistani city of Quetta are said to be Afghans who prefer travelling abroad to making do with the health-care facilities at home. Since the overthrow of the Taliban regime in 2001 and the ensuing flood of aid money, the Afghan government and donors have established a nationwide health-care system almost from scratch. government has contracted nongovernmental organizations to provide a basic package of services in areas that it cannot cover. This arrangement has left the government and more precisely the Ministry of Health to focus on a stewardship role that involves policy and strategy setting, coordination, contract management and monitoring and evaluation. Despite its flaws, health-care experts say the funding and delivery of health care in Afghanistan have taken remarkable strides over the past few years. Merlin is a nongovernmental organization that delivers health services to people living in inaccessible regions, such as Badakhshan province in north-eastern Afghanistan. The gains ... have been fantastic, says Ben Mascall, country director for Merlin. Some of the people we reach have never seen a doctor before, he says. Although some serious medical conditions require treatment that is not available, the presence of basic community clinics helps limit out-of-pocket expenses for minor complaints. Although there have been enormous gains, Dr Abdul Wall Ghayur, from the Ministry of Public Health, admits that all measures, the people of Afghanistan fare far worse, in terms of their health, than any other country of the region. He also claims that the services delivered to the population over the last six years have increased substantially with impressive results. Now attention should be paid to improve the quality of the Basic Package of Health Services, improve hospital and referral systems and initiate partnerships with private providers in the hospital sector to make sure the health problems are addressed. This will require sustained efforts of all partners. Financing for the health system comes from three main sources: external funding from donors, public funding from the government and out-of-pocket spending by patients. …

Poverty, vulnerability, and provision of healthcare in Afghanistan

This paper presents findings on conditions of healthcare delivery in Afghanistan. There is an ongoing debate about barriers to healthcare in low-income as well as fragile states. In 2002, the Government of Afghanistan established a Basic Package of Health Services (BPHS), contracting primary healthcare delivery to non-state providers. The priority was to give access to the most vulnerable groups: women, children, disabled persons, and the poorest households. In 2005, we conducted a nationwide survey, and using a logistic regression model, investigated provider choice. We also measured associations between perceived availability and usefulness of healthcare providers. Our results indicate that the implementation of the package has partially reached its goal: to target the most vulnerable. The pattern of use of healthcare provider suggests that disabled people, female-headed households, and poorest households visited health centres more often (during the year preceding the survey interview). But these vulnerable groups faced more difficulties while using health centres, hospitals as well as private providers and their out-of-pocket expenditure was higher than other groups. In the model of provider choice, time to travel reduces the likelihood for all Afghans of choosing health centres and hospitals. We situate these findings in the larger context of current debates regarding healthcare delivery for vulnerable populations in fragile state environments. The 'scaling-up process' is faced with several issues that jeopardize the objective of equitable access: cost of care, coverage of remote areas, and competition from profit-orientated providers. To overcome these structural barriers, we suggest reinforcing processes of transparency, accountability and participation.

La reconstruction du système de santé en Afghanistan: le rôle des acteurs internationaux sur la prise de décision du gouvernement transitoire afghan

ABSTRACT This article summarizes research seeking to measure the influence of external actors on the interim Afghan government's maternal mortality reduction policy and planning. The author studied the pathways of influence in relations between the Afghan Ministry of Health and key actors in the country's reconstruction during the transitional period (2002–2004), while measuring possible impacts on Afghanistan's health care system. A survey of critical perspectives on reconstruction help to nuance the author's conclusions. Her research demonstrates that external actors exert a relatively high degree of influence on the maternal health care in Afghanistan.

Health Care in Afghanistan

Health Care in Afghanistan

The battle for access--health care in Afghanistan.

Recent rounds on the infectious disease ward in Mir Wais Hospital, in Kandahar, Afghanistan, found a young farmhand recuperating from meningitis sitting with the two friends who had accompanied him to the hospital. He had survived the disease, but only barely, and the episode had left him blind. In quiet tones, the man discussed with the medical staff whether his condition was permanent. In another room, a family of six was recovering from typhoid fever. The family members were fortunate that they had sought care early, because typhoid has a fatality rate of nearly 10 percent in Kandahar. The most . . .