Analysis of equity in utilization of health services in Afghanistan using a national household survey
Journal of Hospital Management and Health Policy
Afghanistan has made significant progress in improving the health status of its population by improving access, coverage, and quality of health services since 2002. As a result, child and maternal mortality rates have considerably decreased. Despite this progress, however, concerns have been increasing over inequity in the utilization of health care. Methods: Data from the Afghanistan Living Conditions Survey (ALCS 2016/17) were analyzed to examine inequities in using health care. Wealth was
... care. Wealth was measured using consumption of both consumables and durable goods. Key health services studied were inpatient and outpatient care use in the public and private sectors. The use of inpatient and outpatient care was compared by wealth status, marriage status, age group, gender, and education level using F tests. Logistic and negative binomial regression models were used to examine factors associated with the utilization of outpatient and inpatient care, respectively. Concentration indexes (CIs), the composite measure of inequalities, were generated for both outpatient and inpatient services, and CIs were broken down by potential drivers of the inequalities. Results: The study shows that households in the wealthiest quintile used more outpatient and inpatient health care compared to those in the poorest quintile. Overall utilization of inpatient and outpatient care was pro-rich, with a CI of 0.123 and 0.174, respectively. There was greater inequality in utilization of health services provided by private health facilities, with a CI of 0.288 and 0.234 for outpatient and inpatient care, respectively. The use of health services in public facilities was more evenly distributed among the population, with CIs close to zero (0.014 and 0.093 for outpatient and inpatient services, respectively). The breakdown of CIs shows that location was one of key drivers of inequalities in utilization of care, which prevailed in both inpatient and outpatient health services. Conclusions: There is significant inequality in the use of inpatient and outpatient care in Afghanistan. Although the utilization of health services in public facilities is more equal, the utilization of care in private facilities is pro-rich. As the private sector provides more than half of outpatient care services, it is critical to address this inequality. Improving physical access and quality of care in public facilities, and expanding programs that address potential financial barriers, could help reduce the inequity.