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Evaluation database

Evaluation report

2017 Afghanistan: Conditional Cash Transfer Scheme to Increase Demand for Maternal and Newborn Health Services Baseline Assessment

Executive summary


Given that only one out of two women in Afghanistan delivery in a health facility and cost is an often cited reason, the Ministry of Public Health (MoPH) and UNICEF designed a pilot conditional cash transfer (CCT) scheme in 2016 for implementation starting just after a baseline assessment to determine whether this approach improves the rate of institutional delivery. Targeting three provinces (Badghis, Bamyan and Kandahar), the CCT scheme provides women with a cash transfer for institutional delivery in an effort to mitigate barriers to accessing health services in Afghanistan, including the cost of transport and other out of pocket expenses. A desired change is that targeted injection of funds will increase demand for institutional delivery by reducing financial constraints. one of the strongest factors of service utilisation according to the 2015 Afghanistan Demographic and Health Survey which found wealth status to be significantly associated with institutional delivery. Community Health Workers (CHW) also receive a cash incentive upon a woman’s delivery. Incentives to CHWs are expected to improve CHW referral systems and motivation to act as an effective bridge between community and facility-based primary health care.


The baseline assessment aims to understand characteristics of the pilot target group and establish baseline values for care-seeking for institutional delivery, antenatal care, postnatal care, as well as stated barriers to seeking care. These baseline values will be compared to second survey conducted after one year of implementation, as well as between treatment and control areas.


The MoPH and UNICEF conducted a consultative workshop with implementing partners and relevant MoPH departments to select six treatment areas, within which all pregnant women and CHWs are eligible to benefit from the CCT programme, and an additional six control areas that will not receive the programme but are similar in other select characteristics. Baseline data were collected in both groups. In November and December 2016, ATR conducted 2400 household questionnaires with women who had given birth in the past two years across 12 districts in three provinces. The household questionnaires collected quantitative data and information on respondents’ demographics, socio-economic status, childbearing history, maternal health seeking behaviour, interactions with community health workers and public health centre service utilisation.

In addition to the 2400 questionnaires, ATR completed nine focus group discussions (FGD) with community leaders and reproductive aged women, and 16 key informant interviews (KII) with midwives, community health workers, and district health workers (DHW). Qualitative data provides a more nuanced understanding of existing constraints to, and uptake of, maternal and newborn health services in the target areas as well as sources of triangulation for quantitative findings

Findings and Conclusions:

The majority of women interviewed who had given birth in the past two years were between 20 and 30 years old, and most had limited access to formal education. Literacy rates among respondents were low in all provinces and did not directly correspond to formal education rates, suggesting that some respondents have access to informal education.

The vast majority of respondents stated that they had visited a health clinic in the past year, and most indicated that the clinic was less than 30 kilometers away. Average transport costs of respondents who had visited the health centre between 1 and 5 times in the past year were reported to be higher in the treatment group (approximately USD $6.25 at the time of the survey) compared to the control group (approximately USD $4.30 at the time of the survey). However, given that women are often excluded from financial transactions and lack numeracy skills, these estimates should be taken with caution.

On average, women had given birth to less than 5 children over their lifetime. Birth rates were slightly higher in Kandahar compared to the other two provinces. This could be because the average age of respondents in Kandahar (30) was higher than the average age of those surveyed in Badghis (27) and Bamyan (28). Nearly two-thirds of respondents had delivered at least one of their children in a health centre. Women were much more likely to use public rather than private services.

Household questionnaire respondents reported that the cost of health services, cost of transport and distance to health centres were, in general, the biggest barriers to accessing institutional delivery, postnatal care and antenatal care. However, there were important differences when comparing districts. For instance, control area respondents in Badghis emphasized familial or cultural barriers as a top three barrier to antenatal care, postnatal care and institutional delivery, while respondents in other districts

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Report information





Health Systems development/management; Primary Health Care; ACSD

Ministry of Public Health, UNICEF



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