Associations between Conflict Severity and Intervention Coverage: Fig. 2 shows the ratings of the provinces based on the conflict severity through the Delphi methodology for the years 2003–2010 and 2010–2018. The trends in the coverage of key RMNCAH&N service indicators suggest that despite being in the midst of conflict, Afghanistan has made progress in improving the coverage of RMNCAH&N service coverage indicators and most of the indicators examined show improvements across the 2003–2015 period. The coverage of ANC and measles immunizations increased at a faster pace in 2003–2010 relative to 2010–2015 and the TT coverage, facility deliveries, SBA, BCG and DPT3/ Penta3 coverage as well as the CCI increased at a faster pace during 2010–2015 (Fig. 3). Coverage of contraceptives increased until 2010, but declined slightly till 2015. The coverage data of several nutrition indicators including early initiation of breastfeeding, exclusive breastfeeding, continued breastfeeding at 2 years and vitamin A supplementation were unreliable in the 2002 surveys, but subsequent surveys have shown reduction in the coverage of most nutrition indicators after the year 2010 (Fig. 4). But even with some progress, there are notable disparities between provinces.
Impact of Conflict: The provinces were rated as in mild-, moderate- and severe conflict for the period of 2003–2010 and 2010–2018 based on both the BRD and the Delphi exercise (Fig. 2). The bivariate analysis based on the BRD classification showed no statistical significant differences in the coverage of RMNCAH&N services between the severe and moderate conflict-affected provinces when compared to mild conflict provinces. The classification using the Delphi methodology shows that the severity of conflict is associated with the health service delivery as the mean difference in the coverage of RMNCAH&N services for the period 2003–2015 was significantly lower for moderate and severely conflict-affected provinces when compared to those minimally affected across a range of indicators (Fig. 5). The multivariate analysis also showed that the coverage for indicators including ANC (OR: 0.42, 95%CI: 0.32–0.55), facility delivery (OR: 0.42, 95%CI: 0.32–0.56), SBA (OR: 0.43, 95%CI: 0.33–0.57), DPT3 (OR: 0.26, 95% CI: 0.20–0.33) and ORT (OR: 0.37, 95% CI: 0.25–0.55) was significantly lower for severe conflict provinces when compared to the minimal conflict provinces. The mean difference in the coverage of EBF under 6 months (OR: 4.44, 95% CI: 1.86–10.61) and BCG (OR: 2.80, 95% CI: 2.09–3.76) was significantly higher in severe conflict compared to the minimal conflict provinces. There was no significant difference in the coverage of contraceptive - any method (OR: 0.98, 95% CI: 0.74–1.30), contraceptive – any modern method (OR: 1.12, 95% CI: 0.83–1.30) and care-seeking for ARI (OR: 0.73, 95%CI: 0.49–1.09). The moderate conflict provinces had a significantly lower coverage of contraceptive- any method (OR: 0.77, 95% CI: 0.66–0.90), contraceptive – any modern method (OR: 0.83, 95% CI: 0.71–0.96), facility delivery (OR: 0.75, 95%CI: 0.58–0.96), BCG (OR: 0.75, 95%CI: 0.58–0.98), DPT/Penta 3 (OR: 0.70, 95%CI: 0.54–0.91), vitamin A supplementation (OR: 0.58, 95% CI: 0.45–0.75), when compared to the minimal conflict provinces (Table 1).
A total of 34 interviews were conducted and the distribution and the demographics of the stakeholders is detailed in Table 2. Following major themes were identified through the key informant interviews and the findings are based on the opinions for most of the stakeholders interviewed (Fig. 6).
Since the past four decades, influence of Taliban and anti-government elements has severely affected the healthcare service delivery in Afghanistan. There were still many areas which were in control of Taliban and some provinces are in grip of continuous war and these areas were the most hard to access and lacked provision of services. These uncertain security conditions had forced many people to move to the adjacent districts (Internally Displaced People (IDPs)) and has disrupted their livelihood, economic status and health.
“Economic situation of people has worsened in war and displacement of people has led to increased incidents of malnutrition in mothers and children, which is another challenge.” [KII-13-NGO-Faryab]
Infrastructure and socio-cultural
Afghanistan has faced numerous challenges related to poor infrastructure and economic distress, as it has been in a state of war for a long time. The poor infrastructure including poor road network, lack of transport, difficult terrain and far away health facilities made health care delivery difficult and inaccessible for people especially living in rural areas. Afghanistan is a male dominant conservative society with high rate of illiteracy, which poses serious barriers to the free movement of women. Some tribes in Afghanistan still prefer being treated by traditional or religious healers rather than a healthcare professional.
“Some religious people misinterpreted Islam and they thought that women have no right to leave her house. She was also not allowed to seek education or work in a health facility.” - [KII-3-UN-Ka]
Prioritizing of interventions
The priority of health service delivery had been on RMNCH&N services through BPHS and EPHS with a specific focus on ANC, care at birth and postnatal care (PNC) and immunization (specifically polio) and a low focus on Expanded Program on Immunization (EPI). The emphasis on increasing awareness and practices for breastfeeding and other preventive measures was lacking and it was suggested to initiate programs solely focusing on improving infant and young child feeding (IYCF) practices in order to prevent undernutrition and reduce childhood morbidity and mortality. The BPHS and EPHS are not fully catering to the health needs of the Afghan population, as there was less or no priority given to important areas including non-communicable diseases, mental health, injuries which share the major burden of disease. The specific focus has also been on the primary healthcare model of BPHS and this has affected tertiary and specialized quality care.
Apart from BPHS, other healthcare programs including vertical programs for specific diseases relied solely on the available funding and particular interest of donors and hence were not sustainable once the funding subsided. The other challenges included weak coordination and interference of political and community leaders.
“Weak coordination at different levels, negative competitions, political and local elders’ interference in the program implementation have a negative impact on the prioritization of interventions” [KII-10-NGO-Faryab]
In the model of BPHS, the service delivery is highly reliant on NGOs with minimum inputs from the existing technical departments within the MoPH, though these technical departments have the required capacity and strong association with development partners. The number of health care facilities are not adequate and are in poor state. Many primary healthcare facilities were non-functional due to insecurity, lack of infrastructure, shortages of staff, severe weather, migrations and poor patient flow. There is a need for regular maintenance and up-gradation of these health facilities for which a specific budget should be in place, together with a mechanism of monitoring. The secondary and tertiary healthcare units were also facing difficulties even in provision of basic care and most of these facilities lacked HIV prevention programs, orthopedic care, dental care, laboratory and screening tests and emergency care.
“The major problem in Faryab province is that we don’t have an emergency hospital for children and for women, we also don’t have facility for STDs, especially for HIV. We also lack services for the management of unintended pregnancies and safe abortion” [KII-1-Gov-Faryab]
The unpredictable security situation, threats, kidnapping and widespread trade of narcotics had left many people deprived of education and prevented people from working. Low salary packages and no facility of accommodation has also refrained experienced health professionals to work in peripheries and hence local hiring was preferred.
“We had a lot of causalities while working here in Helmand. We lost a lot of our field workers during these years. We lost vaccinators, supervisors and coordinators.” [KII-10-UN-Helmand]
The societal norms and restrictions imposed on women by Taliban had left most of the women uneducated over the years and together with the ongoing conflict had led to major deficiency of female doctors, midwives or nurses. NGOs working in the northern parts of the country in the past used to hire female doctors from neighboring countries like Tajikistan and Uzbekistan, as they shared the same language and culture and these workers were provided attractive salary packages, accommodation and transport. But with escalating conflict and unattractive salary packages with rising inflation and depreciation of Afghanistan currency, these foreign workers are no more attracted to work in Afghanistan. The community midwifery program which began training rural midwives in 2002 and scaling-up nationally in 2005 is largely seen as a successful program, which to a certain extent had been able to provide healthcare services to women in these difficult areas.
“There are some socio-cultural and religious issues. Clients will not attend the health facilities if there are no female staff” [KII-7-NGO-Ka]
The recruitment process was a lengthy and tedious process and not always transparent. The government hiring’s had to follow the national standard salary policy which were not competitive enough to attract qualified and competent individuals, as they were lured by the NGOs and the private sector through better packages. Hence the reliance has been to hire local health workers to overcome the shortcomings in resource constrained settings.
“The recruitment process is very difficult and everyone knows this as a fact, but we try our best to recruit the staff through a recruitment committee, and we try to find qualified staff” [KII-6-UN-Helmand]
In terms of development of human resources, there is no proper coordination between MoPH and the ministry of higher education and cross-sectional and interlinked coordination can promote public health education by improving ethics and capability in healthcare professionals.
Supplies and commodities
Government and NGOs were responsible to assure continuous flow of medicine and supplies, but this was a serious concern. The health facilities faced shortages of supplies due to insufficient budget allocation and security situation affecting delivery. Most of the local market suppliers were not equipped to meet the government regulatory requirements, hence a limited number of suppliers were available which were not enough to meet demands of all the 34 provinces. On the contrary, some participants mentioned that there were no shortages of medicines and were satisfied with the availability of supplies and commodities.
“We had multiple developmental projects, but due to unavailability of budget and commodities, we were unable to start these projects and some even got delayed for years” [KII-1 Gov-Faryab]
Afghanistan is a donor dependent country with a major chunk of these funds diverted towards war and security. The ministry has been receiving funds from World Bank (WB), European Union (EU), and United States Agency for International Development (USAID) for the successful implementation of BPHS services and also from GAVI for EPI. The budget allocation in Afghanistan takes place at the central level but lack of capacity, inadequate fund distribution, delay in release of funds and improper utilization poses major barriers to the successful implementation of the programs. This was a common realization that the donor support would end soon and government would then face an uphill task in maintaining even the current healthcare services. Hence it was urged that the government should soon explore alternate ways and finding solutions for the financing of the health system.
“The achievements which we had in the past or even we have now is the result and outcome of our joint force and ownership and the funding from our donors.” – (Govt. official)
The coordination between various sectors is crucial for the efficient healthcare service delivery. Though there were coordination mechanisms in place at the central and provincial level including the Provincial Health Coordination Committee (PHCC), Community Based Health Care (CBHC), but these are not fully utilized as these committees did not regularly meet and there are no proper follow ups to monitor the progress. This apart from affecting healthcare delivery also sometimes led to duplication of effort.
Monitoring and evaluation (M&E)
There was no proper M&E system of Afghanistan, but there has been progress with introduction of regular checks and third party evaluations. There are now Standard Operating Procedures for the evaluation of NGOs performances. Technology has also been introduced with an upgraded digital EHIS system linking all the facilities. But there are still issues with the capacity and monitoring, as majority of the EHIS data was assumed to be poor quality and unreliable. The lack of capacity also hampered the regular and proper analysis and interpretation of data for reporting and decision making. Security was identified as the major bottleneck in monitoring and evaluation, as the supervisors were not able to make frequent visits to the monitoring sites.