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Association between health workforce capacity and quality of care for children under five in Afghanistan

Future Health Systems

Objective: To determine the association between health workforce capacity and quality of care in primary care facilities providing a basic package of health services (BPHS) in Afghanistan.

Since 2004, annual performance assessments were conducted nationally in >600 health facilities including district hospitals, on a sample of >2300 patients under five years, and >1300 health providers selected by stratified random sampling. The assessments included health system capacity measures for provider adequacy, knowledge and training, infrastructure, essential medicines, equipment and availability of clinical guidelines. Quality of care was defined as adherence to the WHO Integrated Management of Childhood Illness (IMCI) clinical guidelines. The findings presented in this study include data from 2005 to 2008.

There was a progressive increase in workforce capacity over the study period, as more health facilities adhered to the BPHS standards for provider staffing Basic Health Centres 75.9% to 85.4% (p<0.001), Comprehensive Health Centres 27.4% to 37.6% (p< 0.03) and District Hospitals (33.3% to 38.1%). Quality of patient assessment and counselling improved significantly for all IMCI index indicators between 2005 and 2008, except for assessment of diarrhoeal symptoms. Health facilities with adequate staffing capacity had significantly higher adherence to IMCI clinical standards of care for years 2006, 2007, and 2008. Other variables significantly associated with quality of care were provider cadre, 
provider gender, age of child, caretaker gender, consultation time, provider knowledge and satisfaction, and availability of clinical guidelines. High patient volume was also significantly associated with better quality of care in 2005 and 2008.

Investments for enhancing the capacity and quality for health service delivery in Afghanistan have illustrated improved health system performance trends measured by the balanced score card since the inception of the basic package of health services. However, severe deficits in professional workforce, particularly in remote and unsecure areas, and the acceleration of internal and external migration, pose enormous challenges to sustaining the gains achieved in service quality and coverage. Aside from ensuring adequacy of the workforce, appropriate investments are required to improve opportunities for professional development and capacity-building, to ensure the competency and satisfaction of health providers delivering care in insecure and complex healthcare environments. 

This study illustrates severe deficits in health workforce both  in  comprehensive health centres and district hospitals. Quality of patient care and outcomes in other studies, have been shown to be associated with provider adequacy, skill mix and distribution of the health workforce. As health systems reconfigure to accommodate new policies and population health needs, balancing the supply and demand for a professional health workforce in a post-conflict context with a high proliferation of local and international NGOs will be a challenge. Future studies and initiatives on human workforce management are mandatory to guide the ministry and foster improved human resource planning for hospitals and health facilities.