Dataset Information

Impact of conflict on maternal and child health service delivery: a country case study of Afghanistan.

ABSTRACT:

Introduction

Since decades, the health system of Afghanistan has been in disarray due to ongoing conflict. We aimed to explore the direct effects of conflict on provision of reproductive, maternal, newborn, child and adolescent health and nutrition (RMNCAH&N) services and describe the contextual factors influencing these services.

Method

We conducted a quantitative analysis of secondary data on RMNCAH&N indicators and undertook a supportive qualitative study to help understand processes and contextual factors. For quantitative analysis, we stratified the various provinces of Afghanistan into minimal-, moderate- and severe conflict categories based on battle-related deaths from Uppsala Conflict Data Program (UCDP) and through accessibility of health services using a Delphi methodology. The coverage of RMNCAH&N indicators across the continuum of care were extracted from the Demographic and Health Surveys (DHS) and Multiple Indicator Cluster Survey (MICS). The qualitative data was captured by conducting key informant interviews of multi-sectoral stakeholders working in government, NGOs and UN agencies.

Results

Comparison of various provinces based on the severity of conflict through Delphi process showed that the mean coverage of various RMNCAH&N indicators including antenatal care (OR: 0.42, 95%CI: 0.32-0.55), facility delivery (OR: 0.42, 95%CI: 0.32-0.56), skilled birth attendance (OR: 0.43, 95%CI: 0.33-0.57), DPT3 (OR: 0.26, 95% CI: 0.20-0.33) and oral rehydration therapy (OR: 0.37, 95% CI: 0.25-0.55) was significantly lower for severe conflict provinces when compared to minimal conflict provinces. The qualitative analysis identified various factors affecting decision making and service delivery including insecurity, cultural norms, unavailability of workforce, poor monitoring, lack of funds and inconsistent supplies. Other factors include weak stewardship, capacity gap at the central level and poor coordination at national, regional and district level.

Conclusion

RMNCAH&N service delivery has been significantly hampered by conflict in Afghanistan over the last several years. This has been further compromised by poor infrastructure, weak stewardship and poor capacity and collaboration at all levels. With the potential of peace and conflict resolution in Afghanistan, we would underscore the importance of continued oversight and integrated implementation of sustainable, grass root RMNCAH&N services with a focus on reaching the most marginalized.

SUBMITTER: Mirzazada S

PROVIDER: S-EPMC7288441 | biostudies-literature | 2020

REPOSITORIES: biostudies-literature

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Impact of conflict on maternal and child health service delivery: a country case study of Afghanistan.

Mirzazada Shafiq S Padhani Zahra Ali ZA Jabeen Sultana S Fatima Malika M Rizvi Arjumand A Ansari Uzair U Das Jai K JK Bhutta Zulfiqar A ZA

Conflict and health 20200610

<h4>Introduction</h4>Since decades, the health system of Afghanistan has been in disarray due to ongoing conflict. We aimed to explore the direct effects of conflict on provision of reproductive, maternal, newborn, child and adolescent health and nutrition (RMNCAH&N) services and describe the contextual factors influencing these services.<h4>Method</h4>We conducted a quantitative analysis of secondary data on RMNCAH&N indicators and undertook a supportive qualitative study to help understand pro ...[more]

PMID: 32536966

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Project description:BackgroundArmed conflict, food insecurity, epidemic cholera, economic decline and deterioration of essential public services present overwhelming challenges to population health and well-being in Yemen. Although the majority of the population is in need of humanitarian assistance and civil servants in many areas have not received salaries since 2016, many healthcare providers continue to work, and families continue to need and seek care.MethodsThis case study examines how reproductive, maternal, newborn, child and adolescent health and nutrition (RMNCAH+N) services have been delivered since 2015, and identifies factors influencing implementation of these services in three governorates of Yemen. Content analysis methods were used to analyze publicly available documents and datasets published since 2000 as well as 94 semi-structured individual and group interviews conducted with government officials, humanitarian agency staff and facility-based healthcare providers and six focus group discussions conducted with community health midwives and volunteers in September-October 2018.ResultsHumanitarian response efforts focus on maintaining basic services at functioning facilities, and deploying mobile clinics, outreach teams and community health volunteer networks to address urgent needs where access is possible. Attention to specific aspects of RMNCAH+N varies slightly by location, with differences driven by priorities of government authorities, levels of violence, humanitarian access and availability of qualified human resources. Health services for women and children are generally considered to be a priority; however, cholera control and treatment of acute malnutrition are given precedence over other services along the continuum of care. Although health workers display notable resilience working in difficult conditions, challenges resulting from insecurity, limited functionality of health facilities, and challenges in importation and distribution of supplies limit the availability and quality of services.ConclusionsChallenges to providing quality RMNCAH+N services in Yemen are formidable, given the nature and scale of humanitarian needs, lack of access due to insecurity, politicization of aid, weak health system capacity, costs of care seeking, and an ongoing cholera epidemic. Greater attention to availability, quality and coordination of RMNCAH services, coupled with investments in health workforce development and supply management are needed to maintain access to life-saving services and mitigate longer term impacts on maternal and child health and development. Lessons learned from Yemen on how to address ongoing primary health care needs during massive epidemics in conflict settings, particularly for women and children, will be important to support other countries faced with similar crises in the future.

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Project description:BackgroundDue to ongoing insecurity, the government of Afghanistan delivers health care to the country's population by contracting out service delivery to non-governmental organization service providers (SPs). In 2018, major changes to SP contracts were introduced, resulting in a new pay-for-performance service delivery model. This model, called "Sehatmandi", pays SPs based on the volume of 11 key services they provide.MethodsA narrative review of Sehatmandi's key features is presented, as well as lessons learned during implementation. Counterfactual comparisons of service delivery data for 10 payment-related service indicators are made. The first comparison is between the rate of change in the volume of services delivered from 2018 to 2019 (ie, the first year of Sehatmandi implementation) relative to the rate change from 2017 to 2018 (ie, prior to the program). The second comparison is between the rate of change in the volume of services delivered in provinces under the pay-for-performance mechanism relative to provinces which were not financed using pay-for-performance. Time trends in non-payment service indicators and service quality are also examined.ResultsThe increase in service volume in Sehatmandi provinces from 2018 to 2019 was higher than the increase from 2017 to 2018 for 8 out of 10 indicators. The median increase in the rate of change was 10 percentage points. Similar results were obtained when comparing pay-for-performance provinces to those not financed using pay-for-performance. Improvements were also observed for services that were not directly compensated by the pay-for-performance approach. Payment for service volume was not associated with reduced service quality. The narrative review suggests that the pay-for-performance system has stimulated more effective oversight of SPs by the government of Afghanistan and has incentivized innovative service delivery strategies by SPs. Sehatmandi may benefit from re-structuring its financial incentives to stimulate improved service quality and accelerate delivery of lagging services.ConclusionsThe available evidence - though subject to some limitations - suggests that the introduction of a pay-for-performance system was associated with an expanded volume of service delivery in Afghanistan. This approach may be beneficial in other conflict-affected countries.

Project description:OBJECTIVES:Only 12 countries in the WHO's African region met Millennium Development Goal 4 (MDG 4) to reduce under-five mortality by two-thirds by 2015. Given the variability across the African region, a four-country mixed methods study was undertaken to examine barriers and facilitators of child survival prior to 2015. Liberia was selected for an in-depth case study due to its success in reducing under-five mortality by 73% and thus successfully meeting MDG 4. Liberia's success was particularly notable given the civil war that ended in 2003. We examined some factors contributing to their reductions in under-five mortality. DESIGN:A case study mixed methods approach drawing on data from quantitative indicators, national documents and qualitative interviews was used to describe factors that enabled Liberia to rebuild their maternal, neonatal and child health (MNCH) programmes and reduce under-five mortality following the country's civil war. SETTING:The interviews were conducted in Monrovia (Montserrado County) and the areas in and around Gbarnga, Liberia (Bong County, North Central region). PARTICIPANTS:Key informant interviews were conducted with Ministry of Health officials, donor organisations, community-based organisations involved in MNCH and healthcare workers. Focus group discussions were conducted with women who have experience accessing MNCH services. RESULTS:Three prominent factors contributed to the reduction in under-five mortality: national prioritisation of MNCH after the civil war; implementation of integrated packages of services that expanded access to key interventions and promoted intersectoral collaborations; and use of outreach campaigns, community health workers and trained traditional midwives to expand access to care and improve referrals. CONCLUSIONS:Although Liberia experiences continued challenges related to limited resources, Liberia's effective strategies and rapid progress may provide insights for reducing under-five mortality in other post-conflict settings.

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Project description:BackgroundProgress in reproductive, maternal, newborn, and child health (RMNCH) in Kenya has been inconsistent over the past two decades, despite the global push to foster accountability, reduce child mortality, and improve maternal health in an equitable manner. Although several cross-sectional assessments have been done, a systematic analysis of RMNCH in Kenya was needed to better understand the push and pull factors that govern intervention coverage and influence mortality trends. As such, we aimed to determine coverage and impact of key RMNCH interventions between 1990 and 2015.MethodsWe did a comprehensive, systematic assessment of RMNCH in Kenya from 1990 to 2015, using data from nationally representative Demographic Health Surveys done between 1989 and 2014. For comparison, we used modelled mortality estimates from the UN Inter-Agency Groups for Child and Maternal Mortality Estimation. We estimated time trends for key RMNCH indicators, as defined by Countdown to 2015, at both the national and the subnational level, and used linear regression methods to understand the determinants of change in intervention coverage during the past decade. Finally, we used the Lives Saved Tool (LiST) to model the effect of intervention scale-up by 2030.FindingsAfter an increase in mortality between 1990 and 2003, there was a reversal in all mortality trends from 2003 onwards, although progress was not substantial enough for Kenya to achieve Millennium Development Goal targets 4 or 5. Between 1990 and 2015, maternal mortality declined at half the rate of under-5 mortality, and changes in neonatal mortality were even slower. National-level trends in intervention coverage have improved, although some geographical inequities remain, especially for counties comprising the northeastern, eastern, and northern Rift Valley regions. Disaggregation of intervention coverage by wealth quintile also revealed wide inequities for several health-systems-based interventions, such as skilled birth assistance. Multivariable analyses of predictors of change in family planning, skilled birth assistance, and full vaccination suggested that maternal literacy and family size are important drivers of positive change in key interventions across the continuum of care. LiST analyses clearly showed the importance of quality of care around birth for maternal and newborn survival.InterpretationIntensified and focused efforts are needed for Kenya to achieve the RMNCH targets for 2030. Kenya must build on its previous progress to further reduce mortality through the widespread implementation of key preventive and curative interventions, especially those pertaining to labour, delivery, and the first day of life. Deliberate targeting of the poor, least educated, and rural women, through the scale-up of community-level interventions, is needed to improve equity and accelerate progress.FundingUS Fund for UNICEF, Bill & Melinda Gates Foundation.

Dataset Information

Impact of conflict on maternal and child health service delivery: a country case study of Afghanistan.

Introduction

Method

Results

Conclusion

Publications

Impact of conflict on maternal and child health service delivery: a country case study of Afghanistan.

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