Saving Mothers and Children in a Post-Conflict Setting: Improving the Quality of Maternal & Child Health Services in Afghanistan
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Date
2018-06-29
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Johns Hopkins University
Abstract
Since the Taliban government was toppled in 2001, Afghanistan has been rebuilding its devastated health system through implementation of the Basic Package of Health Services (BPHS). The BPHS was initiated in 2003 and subsequently complemented by integration with the Essential Package of Hospital Services (EPHS) in 2005. Together, the BPHS and EPHS form the core of Afghanistan’s main health care delivery system. Since the initiation of BPHS, one of the key strategies has been improving the quality of maternal and child health services in Afghanistan. This dissertation focuses on the quality of maternal and child health services and assesses the effects of improving quality of services provided at frontline facilities on selected key outcomes. Study Aim 1 (SA (1)) is to quantify the association between the structural quality of maternal health services and utilization of institutional delivery services. Study Aim 2 (SA (2)) is to estimate the association between health workers’ adherence to clinical guidelines for Integrated Management of Childhood Illnesses (IMCI) and their likelihood of providing accurate diagnosis for pneumonia and diarrhea in children under 5 years of age.
The analyses in the dissertation draw on 8 rounds of nation-wide data collected between 2004 and 2013 as part of National Health Service Performance Assessments in Afghanistan. Each year’s sample included a stratified random sample of different types of health facilities and systematic random samples of patients and health workers in the chosen facilities. The longitudinal and multilevel data analysis methods employed in SA (1) and (2) respectively, take advantage of the temporality of datasets and control for clustering in accordance with the sampling methods.
The analysis for SA (1) provides strong evidence that structural quality improvement of maternal health services was positively associated with increases in facility births. Facilities supported by Non-Governmental Organizations (NGO) had higher institutional delivery rates than did facilities without any support. Increased rates of institutional deliveries were also associated with higher level facilities, a higher number of staff, and higher total volume of non-delivery services at the facilities. The analysis for SA (2) found a significant positive association between process quality of pediatric care, as measured by health workers’ adherence to IMCI clinical guidelines, and their likelihood of providing accurate diagnosis for pneumonia and diarrhea for children under 5 years of age. The analysis also indicated that context mattered, i.e. there were contextual factors at the province level at play either positively or negatively affecting accurate diagnosis, which lies at the heart of successful clinical management of the two diseases. The findings also highlighted that there is considerable room to strengthen IMCI skills and performance of health workers to reduce under-diagnosis of children with serious illnesses.
The dissertation adds evidence, from post-conflict Afghanistan, that improving quality of maternal and child health services can contribute to increased service utilization by mothers, as well as to more accurate diagnoses of the top two diseases that kill children. Since quality improvement, increased utilization rates and more accurate diagnoses are part of key strategies for tackling maternal and child morbidity and mortality, the findings should stimulate continued investment in, and focus on, improving the quality of health services in Afghanistan through the BPHS and EPHS. The findings also serve as a reminder that health systems strengthening efforts should be contextualized at appropriate levels, i.e. individual, facility, provincial or national, through an ongoing exchange of insight and evidence among multiple stakeholders at and between different levels.
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Keywords
Maternal and Child Health, Maternal, Neonatal and Child Health, Afghanistan, Health Systems Strengthening, IMCI