Background: There is global agreement that well-functioning health systems are needed to reduce maternal mortality. There is less agreement, however, on what constitutes a functional health system in fragile states or on how to strengthen the capacity of a health system to ensure that all women have access to safe delivery services and timely emergency obstetric care. This dissertation examines the relationship between implementation of a national primary health care package and coverage of safe delivery services in Afghanistan, and identifies barriers that must be addressed to ensure that all women with obstetric complications have access to good quality medical treatment without delay. Methods: Paper 1 examines the relationship between implementation of Afghanistan’s Basic Package of Health Services and skilled birth attendance using routine data from the Ministry of Public Health from 2006 through 2010 and annual evaluations of health system performance in 29 of the country’s 34 provinces. Paper 2 assesses the contribution of health system factors to skilled birth attendance coverage using data from a 2010 household survey conducted in nine provinces of north-central Afghanistan. Paper 3 analyzes information from government and non-government organization reports, routine health service statistics, in-depth interviews and focus group discussions to compare barriers to scale-up of intrapartum care services in four districts where maternal mortality studies were conducted in 2002 and 2011.Results: Results of Paper 1 show a direct relationship between overall health system performance and skilled birth attendance in Afghanistan. Findings suggest that approximately half of the variation in skilled birth attendance rates across provinces can be explained by health facility density and service package implementation, while the remaining variation is likely associated with provincial characteristics not captured in this study. Paper 2 did not show any direct linkages between health facility characteristics and an individual woman’s likelihood of skilled birth attendance, but provided insights into why studies assuming that women seek care at the nearest primary health care facility may lead to misinterpretation of care-seeking patterns or mask the relationship between perceptions of service quality and skilled birth attendance utilization. Paper 3 illustrated the importance of context when evaluating factors that facilitate and hinder safe delivery and emergency obstetric service coverage. When asked about barriers to utilization of intrapartum care services, three common themes highlighted by national policymakers, provincial and district-level healthcare providers, and community members were: (1) structural barriers such as lack of infrastructure or human resource shortages limiting availability of services, (2) programmatic barriers such as limited technical capacity hindering provision of quality care, and (3) contextual barriers affecting when, where and why women deliver at facilities. Conclusions: Together, the three papers presented in this dissertation show that while there is a strong relationship between primary health care service package implementation and coverage of safe delivery services in Afghanistan, roll-out of this service package may not be an effective approach for scaling up services in extremely remote or insecure settings.Improvements in maternal health services coverage must be measured at a sub-national level, and health care service packages adapted to consider the needs and preferences of households in hard-to reach areas. For example, strategic human resource deployment, investment in referral systems and targeted interventions to strengthen community-facility linkages may be required to extend service coverage in remote areas. Thus, more context specific planning and adaptation of health care service packages at the provincial or district level are recommended. Study findings also illustrate the complexity of health policy planning and resource allocation in conflict-affected settings, and suggest that alternatives to the current service delivery strategy be considered in these areas.
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Strengthening Afghanistan's Health System to Save Women's Lives: Achievements and Gaps in Scale-Up of Safe Delivery Services