Equity of maternal and child health services in Afghanistan: a spatiotemporal analysis of national survey datasets

Abstract

Introduction: Afghanistan's healthcare system faces geopolitical instability and inequities in maternal and child health (MCH) services, particularly associated with a temporary collapse in funding in 2021. We analysed coverage levels and spatiotemporal trends in sociodemographic inequalities in the country using data from the 2010/2011 and 2022/2023 Afghan Multiple Indicator Cluster Surveys.

Methods: The study's primary outcome was an adapted Composite Coverage Index (CCI) that combined seven essential MCH interventions with corresponding inequality measures, evaluated using Slope Indices of Inequality. These interventions included antenatal care, skilled birth attendance (SBA), Bacillus-Calmette-Guérin (BCG), diphtheria-pertussis-tetanus, and measles vaccination and treatment for suspected pneumonia and diarrhoea. Inequalities were analysed across wealth, education and urban/rural status at both national and provincial levels.

Results: The analysis revealed persistent socioeconomic inequalities across all strata, with the most significant economic disparities observed in SBA and the largest educational disparities in vaccine coverage in 2022/2023. Nationally, the CCI increased by 4.2% from 42.1% (95% CI 40.3% to 44%) in 2010/2011 to 46.2% (95% CI 44.6% to 47.9%) in 2022/2023. Despite a slight increase between the two studies, severe regional disparities are masked, particularly in the eastern and southern regions, where coverage across multiple interventions significantly declined. The provinces of Nooristan and Urozgan significantly lost coverage, while Daykundi and Nimroz recorded increases in coverage and equity.

Conclusion: The findings underscore the persistence of substantial inequalities in Afghanistan, with severe consequences for already vulnerable populations facing multiple hardships. The findings highlight ways in which geopolitical instability affects healthcare equity. Increasing disparities threaten to exacerbate existing challenges in accessing essential healthcare services, particularly for those of lower socioeconomic status. Urgent, targeted interventions are necessary to address these inequities, the impacts associated with funding cuts and gender marginalisation, and to mitigate their detrimental impact on Afghan women and children.

Keywords: Child health; Delivery of Health Care; Geographic information systems; Health Services Accessibility; Maternal health.

Figure 1. Equiplots for all three equity dimensions comparing both time points for each of the seven interventions. A connecting line indicates the presence of all individual substrata and is connecting lowest to highest values. (A) Equiplot comparing each intervention by the two time points stratified by wealth quintiles. (B) Equiplot comparing each intervention by the two time points stratified by maternal education level. (C) Equiplot comparing each intervention by the two time points stratified by area of residence. ANC4, 4 or more antenatal care (ANC) visits; DPT3, 3 doses of at least a tetravalent diphtheria-pertussis-tetanus vaccination; ORS, treatment of diarrhoeal diseases with oral rehydration solution or salts; SBA, skilled birth attendance; BCG, Bacillus-Calmette-Guérin vaccination; MSL, first dose of the measles vaccination schedule; ARI, care seeking with a skilled provider for children with acute respiratory illness, that is, suspected pneumonia.

Figure 2. Spatial distribution of mean coverage rates for skilled birth attendance, BCG immunisation and oral rehydration therapy for each of the 34 Afghan provinces. Exact values with corresponding 95% CIs are included in online supplemental table 3. Skilled birth attendance: (A) mean coverage of skilled birth attendance per province in the 2010/2011 survey; (B) mean coverage of skilled birth attendance per province in the 2022/2023 survey. BCG immunisation: (C) mean coverage of BCG immunisation per province in the 2010/2011 survey; (D) mean coverage of BCG immunisation per province in the 2022/2023 survey. Oral rehydration therapy: (E) mean coverage of oral rehydration therapy per province in the 2010/2011 survey; (F) mean coverage of oral rehydration therapy per province in the 2022/2023 survey.

Figure 3. Spatial distribution of mean coverage rates for Composite Coverage Index (CCI) for each of the 34 Afghan provinces. Exact values are included in online supplemental table 4. (A) Mean CCI for each Afghan province in the 2010/2011 survey. (B) Mean CCI for each Afghan province in the 2022/2023 survey.