From 2011 to 2018, 142,797 bacteriologically confirmed TB cases were diagnosed in Afghanistan. The number of household members eligible for screening was estimated to be 856,782, of whom 586,292 (81%) were screened for TB and 117,643 (20.1%) were found to be presumptive TB cases. Among the cases screened, 10,896 TB cases (all forms) were diagnosed, 54.4% in females. The number needed to screen to diagnose a single case of TB (all forms) was 53.8; the number needed to test was 10.7. Out of all children under five, 101,084 (85.9%) were initiated on IPT, and 69,273 (68.5%) completed treatment. The study concluded that program performance in contact screening in Afghanistan is high, at 81%, and the yield of TB is also high—close to 10 times higher than the national TB incidence rate. IPT initiation and completion rates are also high as compared to those of many other countries but need further improvement, especially for completion.

We used a qualitative approach to explore the contribution of contextual, individual, household-level and health system factors to stillbirth in Afghanistan. We conducted semi-structured in-depth interviews with women and men that experienced stillbirth, female elders, community health workers, healthcare providers, and government officials in Kabul Province, Afghanistan, between October-November 2017. We used thematic analysis to identify contributing factors and developed a conceptual map describing possible pathways to stillbirth. We found that low utilisation and access to healthcare was a key contributing factor, as were unmanaged conditions in pregnancy that increased women’s risk of complications and stillbirth. Sociocultural factors related to the treatment of women and perceptions about medical interventions deprived women of interventions that could potentially prevent stillbirth. The quality of care from public and private providers during pregnancy and childbirth was a recurring concern exacerbated by health system constraints that led to unnecessary delays; while environmental factors linked to the ongoing conflict were also perceived to contribute to stillbirth. These pathways were underscored by social, cultural, economic factors and individual perceptions that contributed to the three-delays.

This study’s objective was to determine the prevalence of TB among mentally ill patients in Afghanistan. A cross-sectional study was conducted in five public health facilities and one private facility. All patients in those centers were screened for TB, and the diagnosis of TB was made with GeneXpert or made clinically by a physician. Out of 8,598 patients registered, 8,324 (96.8%) were reached and 8,073 (93.9%) were screened for TB, of whom 1,703 (21.1%) were found to be presumptive TB patients. A total of 275 (16.7%) were diagnosed with all forms of TB, of whom 90.5% were women. The overall prevalence of TB among mentally ill patients was 3,567/100,000—20 times higher than the national incidence rate. TB was independently associated with married and widowed adults, young adults, females, and oral sleep drug users. TB among mentally ill patients is very high, and we recommend that TB care and prevention services be integrated into mental health centers.

In this qualitative study, we aimed to understand how community and healthcare providers' perceptions and practices around stillbirth influence stillbirth data quality in Afghanistan. We collected data through 55 in-depth interviews with women and men that recently experienced a stillbirth, female elders, community health workers, healthcare providers, and government officials in Kabul province, Afghanistan between October-November 2017. The results showed that at the community level, there was variation in local terminology and interpretation of stillbirth which did not align with the biomedical categories of stillbirth and miscarriage and could lead to misclassification. At the facility level, we identified that healthcare providers' practices, driven by institutional culture and demands, family pressure, and socio-cultural influences, could contribute to under-reporting or misclassification of stillbirths. Data collection methodologies need to take into consideration the socio-cultural context and investigate thoroughly how perceptions and practices might facilitate or impede stillbirth reporting in order to make progress on data quality improvements for stillbirth.

Stillbirth rates in Afghanistan have declined little in the past decade with no data available on key risk factors. Health care utilisation and maternal complications are important factors influencing pregnancy outcomes but rarely captured for stillbirth in national surveys from low‐ and middle‐income countries. The 2010 Afghanistan Mortality Survey (AMS) is one of few surveys with this information. We used data from the 2010 AMS that included a full pregnancy history and verbal autopsy. Our sample included the most recent live birth or stillbirth of 13 834 women aged 12‐49 years in the three years preceding the survey. The risk of stillbirth was increased among women in the Central Highlands and of Nuristani ethnicity. Women who did not receive antenatal care had three times increased risk of stillbirth, while high‐quality antenatal care was important for reducing the risk of intrapartum stillbirth. Bleeding, infection, headache, and reduced fetal movements were antenatal complications strongly associated with stillbirth. Reduced fetal movements in the delivery period increased stillbirth risk by almost seven. Facility births had a higher risk of stillbirths overall, but not for intrapartum stillbirths. Targeted interventions are needed to improve access and utilisation of services for high‐risk groups. Early detection of complications through improved quality of antenatal and obstetric care is imperative. We demonstrate the potential of household surveys to provide country‐specific evidence on stillbirth risk factors for LMICs where data are lacking.

This quasi-experimental study conducted in Afghanistan examines the causal impact of a provincial health governance intervention on the provincial health system’s performance. It compares health system performance indicators between 16 intervention provinces and 18 nonintervention provinces using a difference-in-differences analysis to draw inference. The intervention consisted of governance action planning, implementation of the governance action plan, and self-assessment of governance performance before and after the intervention. The intervention had a statistically and practically significant impact on six indicators.

To determine if children presenting without complaints related to the Integrated Management of Childhood Illness (IMCI) are at greater risk for suboptimal screening for IMCI conditions, we randomly sampled and observed 3072 sick child visits in 33 provinces of Afghanistan. The study indicated that children with non-IMCI complaints are at greater risk of suboptimal screening compared to children with IMCI-related complaints. We concluded that facility and provider capacity needs to be improved, particularly during training, supervision and guideline dissemination, to ensure that all children receive routine screening for common IMCI conditions.

Tuberculosis (TB) is a major public health problem in Afghanistan, but experience in implementing effective strategies to prevent and control TB in urban areas and conflict zones is limited. This study shares programmatic experience in implementing DOTS in the large city of Kabul. We analyzed data from the 2009–2015 reports of the National TB Program (NTP) for Kabul City and calculated treatment outcomes and progress in case notification. Between 2009 and 2015, the number of DOTS-providing centers in Kabul increased from 22 to 85. In total, 24,619 TB patients were enrolled in TB treatment during this period. The case notification rate for all forms of TB increased from 59 per 100,000 population to 125 per 100,000. The case notification rate per 100,000 population for sputum-smear-positive TB increased from 25 to 33. The treatment success rate for all forms of TB increased from 31% to 67% and from 47% to 77% for sputum-smear-positive TB cases. In 2013, contact screening was introduced, and the TB yield was 723 per 100,000—more than two times higher than the estimated national prevalence of 340 per 100,000. Contact screening contributed to identifying 2,509 child contacts of people with TB, and 76% of those children received isoniazid preventive therapy. The comprehensive urban DOTS program significantly improved service accessibility, TB case finding, and treatment outcomes in Kabul. Public- and private-sector involvement also improved treatment outcomes; however, the treatment success rate remains higher in private health facilities. While the treatment success rate increased significantly, it remains lower than the national average, and more efforts are needed to improve treatment outcomes in Kabul. We recommend that the urban DOTS approach be replicated in other countries and cities in Afghanistan with settings similar to Kabul.

The study aimed to conduct capacity assessments of the community health worker (CHW) system and determine stakeholder perspectives of CHW performance. Formative assessments evidenced that CHWs were highly valued as they provided equitable, accessible and affordable 24-hour care. Their loyalty, dedication and the ability for women to access care without male family escorts was appreciated by communities. With rising concerns of workforce deficits, insecurity and budget constraints, the health system must enhance the capacity of these frontline workers to improve the continuum of care.

We piloted an intervention that placed a people-centred health systems governance approach in the hands of multi-stakeholder committees that govern provincial and district health systems in Afghanistan. We report the results of this intervention from three provinces and eleven districts in Afghanistan over a six month period. This mixed-methods exploratory case study uses analysis of governance self-assessment scores, health management information system data on health system performance, and focus group discussions. The outcomes of interest are governance scores and health system performance indicators. We document the application of a people-centred health systems governance conceptual model based on applying four effective governing practices: cultivating accountability, engaging with stakeholders, setting a shared strategic direction, and stewarding resources responsibly. We found that health systems governance can be improved in fragile and conflict affected environments, and that consistent application of the effective governing practices is key to improving governance. Intervention was associated with a 20% increase in antenatal care visit rate in pilot provinces.


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