Published on July 20, 2009
Obstacles to maternity service use in Afghanistan: what do we know about cost, quality and access? Sandhya Sundaram, Laura Steinhardt, David H. Peters, M. Hafizur Rahman Johns Hopkins Bloomberg School of Public Health July 14, 2009
Background (1) Poor maternal and neonatal health outcomes High maternal mortality - 1,600 deaths/100,000 live births nationally (Range: 400/100,000 - 6,500/100,000) Estimated 70-80% maternal deaths due to preventable causes Low maternal health service utilization levels Skilled antenatal care service use: 14% (2003 MICS) → 28% (2006 AHS) Skilled birth attendance: 13% (2003 MICS) → 19% (2006 AHS) Wide rural/urban gaps
Background (2) Accessibility to public sector maternal health services greatly improved Capacity to provide services has increased from 23.4% to 71.9% of public sector facilities Supply of maternal health care services has increased, but utilization does not seem to have kept pace. Physical and financial accessibility still problematic
Data Sources – Quantitative National Risk & Vulnerability Assessment (NRVA) 2005 Poverty and vulnerability survey - LSMS with MCH module Multistage cluster sample Almost 31,000 households Data presented today: ~13,500 deliveries in previous 2 years Health Financing Pilot Intervention Project (HFP) 2007 Evaluation of health financing pilot project – community health insurance, user fees Cluster sample in 24 health facility catchment areas 1,158 households across 49 clusters
Data Sources – Qualitative Community Health Worker Study 2006 Focus group discussions (FGDs) with facility health committees, community health committees, and community members Focus on community perceptions of CHWs Maternal Health Care Service Utilization Study 2007 Semi-structured interviews, FGDs Variety of respondents Data presented today – focus on women and men in communities, and women using facilities and their companions
Methodology – Analysis Survey data Bivariate analyses Multivariate analyses Qualitative data No audio-taping for security reasons Transcription and translation Coding Textual analysis
Access I ** p<0.01; *** p<0.001 Note: ORs adjusted for reproductive history, wealth status, access to credit, province, and other factors Source: National Risk and Vulnerability Assessment (NRVA) Survey 2005.
Access II Distance the most-often reported barrier to service use Cited by 75% of facility patients and companions; 92% of FGDs Services within 7 hrs’ walking distance considered accessible Poor access to transportation severely restricts service use 2/3 of facility patients; 3/4 FGD participants Even when facilities are near, trained staff not always available CHWs a valued source of delivery services Nearly 2/3 of CHWs surveyed in 2005-2007 reported assisting with home deliveries Community members suggested CHWs need adequate supplies, drugs, and a salary to be more helpful
What do people say about access? I don't go to clinic for delivery because my delivery takes a short time. The clinic is far away and there is no care to use and it is possible that delivery occurs in the middle way. Other people also have the same problem… I have lost 3 of my children because after delivery, the placenta is not delivered soon and I have too much bleeding. But because of the distance and problem of transport, I cannot go to the clinic. (Facility patient, female, 30 yrs., 2007) Source: 2007 maternal health service use qualitative study
Cost I ** p<0.01; *** p<0.001 Note: ORs adjusted for reproductive history, travel time, province, and other factors Source: National Risk and Vulnerability Assessment (NRVA) Survey 2005.
Cost II User fees for curative care deterred use of maternal health services Use of facility for delivery greater among households w/ fee waiver card (despite free delivery care) 0.12 deliveries in last 6 months per household w/o waiver card vs. 0.29 w/card, (p=0.001)* * Controlling for province, wealth, walking distance to facility, and facility type Sources: 2005 NRVA and 2007 HFP Evaluation survey .
Cost III More than half of facility patients and their companions, and participants in more than half of FGDs, reported household poverty and high care-seeking costs as barriers to skilled attendance at delivery Service costs relatively standard for primary care, but vary substantially for secondary and tertiary care Drug and transportation costs highly variable Financial costs of care-seeking—service costs (private), drug costs, transportation costs and baksheesh—are prohibitive Household poverty—financial poverty and lack of access to credit—prevents women from using services In emergencies, households often have to seek loans to support care-seeking and may experience difficulty securing funds Source: 2007 maternal health service use qualitative study
What do people say about cost? Respondent 9: I have gone to the clinic once for check up, but they did not give me medicine, and give me the prescription for the bazaar, however we our economy is too weak then I could not buy these medicines. Respondent 10: I got information from the midwife, and she told me you must get some … medicines, and it will cost about 1000 Afghanis, but I [did] not have the amount and the clinic did not give me medicine. (Focus group discussion, child-bearing age women) Source: 2007 maternal health service use qualitative study
Quality Most respondents feel availability & quality have improved Respondents care about how providers treat patients Being treated with respect; privacy and female providers for female patients Drug availability and effectiveness matter Some respondents feel they have been properly treated only if they receive drugs Perceptions of poor drug quality or low stock may cause clients to seek care elsewhere Respondents appreciate fairness in facility procedures Seeing patients in order, emergency patients first Reports of patronage systems resulting in inequitable access Female providers and 24-hour access are important Source: 2007 maternal health service use qualitative study
Conclusions Distance – compounded by transportation availability – emerged as top barrier to maternal health service utilization Non-services costs (e.g., medication, transportation, baksheesh) can be strong deterrents to care-seeking Lack of female providers, lack of privacy, and drug stock-outs were important barriers to care-seeking
Policy recommendations Need to address accessibility issues, particularly times of service availability, availability of skilled care for home-based deliveries, and transportation availability More focus on birth planning, so households are prepared for regular births and for emergencies (e.g., emergency funds, transportation) Re-think role of CHWs in delivery (e.g., stronger links to midwives, incentives for facility referral)
Thank you Acknowledgments: Johns Hopkins University Technical Assistance Project, Future Health Systems: Innovations for Equity, Ministry of Public Health (Afghanistan), Central Statistics Office (Afghanistan) Author contact info: Sandhya Sundaram: firstname.lastname@example.org Laura Steinhardt: email@example.com David Peters: firstname.lastname@example.org M. Hafizur Rahman: email@example.com
Discussion Factors that were difficult to measure accurately: Security/conflict (in quantitative data) NRVA Data limitations Missing data in NRVA One province (Zabul) missing due to security Unable to link to age of women in HH register (used age at marriage) Other issues to consider: ??
What do people say about quality? They pay attention to the customs of people. Today I came from the hospital. I saw they were paying attention to all customs of people. Female doctors were checking female patients, and male doctors were checking male patients and female section was separated form the male section. No activity of the doctors is against the custom of people. (Facility patient, female, 24 yrs., 2007) Source: 2007 maternal health service use qualitative study
Access, cost & quality intersect: illustrations Access and cost In my opinion their [CHWs’] service during delivery is most useful not only for me, but for all of village’s residences, since we all are poor people and can’t afford to get a taxi for our patient to take her to the clinic or hospital, at mean time we call CHW and she is always ready to serve for us during the night as well as during the day. (Female community member, Balkh province, 2006) Access, cost and quality Respondent: I do not want to come to the clinic or if it is needed then we go to the _____ bazaar. Interviewer: Why? Can you describe it? Respondent: Because the distance to the clinic is too long, and it is the same [services provided when we] go to _____ bazaar. They cost equal. (Facility patient, female, 35 yrs., 2007) Sources: 2006 CHW perceptions study and 2007 maternal health service use qualitative study.
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