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.
FHS Phase 1
Since 2003, the Johns Hopkins Bloomberg School of Public Health (JHSPH) and the Indian Institute of Health Management Research (IIHMR) have been working with the Ministry of Public Health (MoPH) in Afghanistan to implement a ‘Balanced Scorecard’ for monitoring the effectiveness of health services across the country. The long-running project, funded directly by the MoPH, offered FHS an important opportunity to feed into ongoing processes in the country, supporting work specifically around maternal health.
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 main effort for FHS in the first phase was 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.
FHS Phase 2 focus
In Afghanistan, the government has made significant improvements in performance of the basic health package of services as illustrated by the results of the balanced scorecard. However, there is inadequate documentation of the institutionalization and effectiveness of these systems, and of communication of results from health facility and community surveys to the peripheral health units and the communities. The results of the scorecard are mainly disseminated at the national and provincial levels and additional efforts must be made to cascade the information to the point of service delivery to enable problem solving strategies for service improvement.
To improve feedback at a community level, FHS's work in Phase 2 is expected to focus on the development and piloting of a community scorecards (CSCs), which have shown promising potential in generating community commitment and empowerment to ensure quality and health service delivery in other settings.