Background The effects of conditional cash transfer (CCT) programs on maternal and child health (MCH) service use in conflicted affected countries such as Afghanistan are not known. Methods We conducted a non-randomised population based intervention study in six Afghanistan districts from December 2016 to December 2017. Six control districts were purposively matched. Women were eligible to be included in the baseline and endline evaluation surveys if they had given birth to one or more children in the last 12 months. The intervention was a CCT program including information, education, communication (IEC) program about CCT to community members and financial incentives to community health workers (CHWs) and families if mothers delivered their child at a health facility. Control districts received standard care. The primary objective was to assess the effect of CCT on use of health facilities for delivery. Secondary objectives were to assess the effect of CCT on antenatal care (ANC), postnatal care (PNC) and CHW motivation to perform home visits. Outcomes were analysed at 12 months using multivariable difference-in-difference linear regression models adjusted for clustering and socio demographic variables. Results Overall, facility delivery increased in intervention villages by 14.3% and control villages by 8.4% (adjusted mean difference [AMD] 3.3%; 95% confidence interval [− 0.14 to 0.21], p value 0.685). There was no effect in the poorest quintile (AMD 0.8% [− 0.30 to 0.32], p value 0.953). ANC (AMD 45.0% [0.18 to 0.72] p value 0.004) and PNC (AMD 31.8% [− 0.05 to 0.68] p value 0.080) increased in the intervention compared to the control group. CHW home visiting changed little in intervention villages (− 3.0%) but decreased by − 23.9% in control villages (AMD 12.2% [− 0.27 to 0.51], p value 0.508). CCT exposure was 27.3% (342/1254) overall and 10.2% (17/166) in the poorest quintile. Conclusions Our study demonstrated that a CCT program provided to women aged 16–49 years can be implemented in a highly conservative conflict affected population. CCT should be scaled up for the poorest women in Afghanistan.

BackgroundIn the past fifteen years, Afghanistan has made substantial progress in extending primary health care. However, coverage of essential health interventions proven to improve maternal and neonatal health outcomes, particularly skilled birth attendance, remains unacceptably low. This is especially true for those in the poorest quintile of the population. This cross-sectional quantitative and qualitative study assessed barriers associated with care-seeking for institutional delivery among rural Afghan women in three provinces.MethodsThe study was conducted from November to December 2016 in 12 districts across three provinces – Badghis, Bamyan, and Kandahar – which are predominately rural. Districts were used as the primary sampling unit with district-level sample sizes reflecting the ratio of that district’s population to provincial population. Villages within these districts, the secondary sampling units, were randomly selected. A household survey was used to collect data on: demographics, socio-economic status, childbearing history, health transport and service costs, maternal health seeking behavior and barriers to service uptake. Data on barriers to facility delivery were compared across provinces using chi square tests.ResultsOf the 2479 women of child bearing age interviewed, one-third were from each province (33% n = 813 Badghis, 34% n = 840 Bamyan, 33% n = 824 Kandahar). Among those respondents who had delivered none of their children in a health center, money to pay for services appeared to be most important barrier to accessing institutional delivery (56%, n = 558). No transportation available was the second most widely cited reason (37%, n = 368), followed by family restrictions (n = 30%, n = 302). Respondents in Badghis reported the highest levels of barriers compared to the other two provinces. Respondents in Badghis were more likely to report familial or cultural constraints as the most important barrier to institutional delivery (43%) compared to Bamyan (2%) and Kandahar (12%) (p < 0.001).ConclusionsDespite the socio-demographic and geographic diversity of the three provinces under study, the top barriers to institutional delivery reported in all three areas are consistent with available evidence, namely, that distance, transport cost and transport availability are the main factors limiting institutional delivery. Proven and promising approaches to overcome these barriers to institutional delivery in Afghanistan should be explored and studied.Electronic supplementary materialThe online version of this article (10.1186/s12884-018-1890-2) contains supplementary material, which is available to authorized users.

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Background Afghanistan’s health system is unique in that primary healthcare is delivered by non-governmental organizations funded by multilateral or bilateral donors, not the government. Given the wide range of implementers providing the basic package of health services, there may be performance differences in service delivery. This study assessed the relative technical efficiency of different levels of primary healthcare services and explored its determinants. Method Data envelopment analysis was used to assess the relative technical efficiency of three levels of primary healthcare facilities (comprehensive, basic, and sub-health centers). The inputs included personnel and capital expenditure, while the outputs were measured by the number of facility visits. Data on inputs and outputs were obtained from national health information databases for 1263 healthcare facilities in 31 provinces. Bivariate analysis was conducted to assess the correlation of various elements with efficiency scores. Regression models were used to identify potential factors associated with efficiency scores at the health facility level. Results The average efficiency score of health facilities was 0.74 when pooling all 1,263 health facilities, with 102 health facilities (8.1%) having efficiency scores of 1 (100% efficient). The lowest quintile of health facilities had an average efficiency score of 0.36, while the highest quintile had a score of 0.96. On average, efficiency scores of comprehensive health centers were higher than basic and sub-health centers by 0.11 and .07, respectively. In addition, the difference between efficiency scores of facilities in the highest and lowest quintiles was highest in facilities that offer fewer services. Thus, they have the largest room for improvement. Conclusions Our findings show that public health facilities in Afghanistan that provide more comprehensive primary health services use their resources more efficiently and that smaller facilities have more room for improvement. A more integrated delivery model would help improve the efficiency of providing primary healthcare in Afghanistan.