Afghanistan

Key research question:

What is the potential role of a demand-side intervention in increasing utilisation of maternal health services in Afghanistan?

By the time the Taliban were overthrown in November 2001, Afghanistan had endured over two decades of conflict. The instability of war combined with existing poor infrastructure, limited access to safe water, sanitation and health services, and poverty, to place Afghanistan among the least developed nations in the world.

Currently, different parts of Afghanistan are at different stages of insecurity—some parts are post-conflict, others are still in-conflict, and others experience periodic conflict. The influx of development funds and private business, as well as growing capacity within Afghanistan, have resulted in a growing pool of actors holding conflicting interests and rapidly changing formal and informal institutions. It is unclear how the context is affecting health service use.

Maternal health is acknowledged to be pivotal in the maintenance of household health and well-being. Maternal health indicators in Afghanistan are among the worst in the developing world. Strong political will and acknowledgment of maternal health as a health and development priority has led to improvements in both the quantity and quality of maternal health services. However, despite the known risks of child-bearing and the increase in supply of services, maternal health care service use remains very low.

The aim of this effort is to understand how vulnerabilities at multiple levels and rapidly changing contextual factors influence utilization of maternal health services by women in Afghanistan, and to determine the kinds of interventions which may increase appropriate utilization of maternal health care services. Key questions to be answered are:

• What individual factors influence utilization of skilled care for routine maternal health needs and obstetric emergencies?
• What household factors may affect capacity to utilize maternal health services, for example household participation in extended family and informal social networks, household participation in economic markets and access to credit, household shocks, and coping strategies for dealing with shocks?
• What community factors may affect capacity to utilize maternal health services, for example geographic factors, community access to public services including health services, community-level decision-making, and community security & stability?
• How do individual, household and community factors interact either to inhibit or enable maternal health service utilization?
• What are the effects on maternal health service use of rapidly changing institutional actors and processes in this context?
• What are program features of interventions which can influence these factors and increase appropriate maternal health care-seeking? How can interventions take advantage of existing institutional arrangements or engender different institutional arrangements to enable maternal health care-seeking?

The FHS-Afghanistan Team will use a combination of in-depth and quantitative research techniques to investigate these questions. Findings will be used to develop a major intervention project to encourage appropriate maternal health service utilization.