title: Trends in the quality of health care for children aged less than 5 years in Afghanistan, 2004-2006.
abstract: OBJECTIVE
  To study trends in the quality of the health care provided to children aged less than 5 years in Afghanistan between 2004 and 2006. In particular, to determine the effect on such quality of a basic package of health services (BPHS), including Integrated Management of Childhood Illness (IMCI), introduced in 2003.
  
  
  METHODS
  In each year of the study, 500-600 health facilities providing the BPHS were selected by stratified random sampling in 29 provinces of Afghanistan. We observed consultations for children aged less than 5 years, interviewed their caretakers, interviewed health-care providers and measured adherence to case management standards for assessment and counselling in a random sample.
  
  
  RESULTS
  The quality of the assessment and counselling provided to sick children aged less than 5 years improved significantly between 2004 and 2006. A 43.4% increase in the assessment index and a 28.7% increase in the counselling index (P < 0.001) were noted. Assessment quality improved significantly every year and was statistically associated with certain characteristics of the provider (being a doctor, having a higher knowledge score, being trained in IMCI, being part of a "contracting-in" mechanism and providing a longer consultation time) and the child (being younger and having a female caretaker). Counselling quality was also significantly associated with these characteristics, except for provider cadre and child age. The presence of clinical guidelines and the frequency of supervision were significantly associated with improved quality scores in 2006 (P < 0.05 and < 0.01, respectively).
  
  
  CONCLUSIONS
  Quality of care improved over the study period, but performance remained suboptimal in some areas. Continued investments in Afghanistan's health system capacity are needed.
authors.affiliation: Johns Hopkins University, 615 North Wolfe Street, Baltimore, MD 21205-2179, United States of America. aedward@jhsph.edu
authors.forename: Anbrasi
authors.initials: A
authors.lastname: Edward
authors.forename: Vikas
authors.initials: V
authors.lastname: Dwivedi
authors.forename: Lais
authors.initials: L
authors.lastname: Mustafa
authors.forename: Peter M
authors.initials: PM
authors.lastname: Hansen
authors.forename: David H
authors.initials: DH
authors.lastname: Peters
authors.forename: Gilbert
authors.initials: G
authors.lastname: Burnham
mesh_terms: D000346:Afghanistan; D019090:Case Management / Q000592:standards; D002675:Child, Preschool; D003376:Counseling / Q000592:standards; D005260:Female; D019983:Guideline Adherence; D006801:Humans; D007223:Infant; D007407:Interviews as Topic; D008297:Male; D011787:Quality of Health Care / Q000639:trends*
references.citation: Bull World Health Organ. 2004 Jul;82(7):509-15
references.pmid: 15508195
references.citation: Lancet. 2004 Oct 30-Nov 5;364(9445):1583-94
references.pmid: 15519628
references.citation: Int J Health Plann Manage. 2008 Apr-Jun;23(2):107-17
references.pmid: 18435428
references.citation: Cad Saude Publica. 2004;20 Suppl 2:S209-19
references.pmid: 15608935
references.citation: Health Policy Plan. 2005 Dec;20 Suppl 1:i42-i48
references.pmid: 16306068
references.citation: Trop Doct. 2002 Jul;32(3):166-7
references.pmid: 12139161
references.citation: Lancet. 2004 Sep 4-10;364(9437):900-6
references.pmid: 15351199
references.citation: Am J Public Health. 2004 Oct;94(10):1686-8
references.pmid: 15451732
references.citation: Arch Dis Child. 2005 Apr;90(4):397-401
references.pmid: 15781932
references.citation: Bull World Health Organ. 2005 Apr;83(4):260-7
references.pmid: 15868016
references.citation: Health Technol Assess. 2004 Feb;8(6):iii-iv, 1-72
references.pmid: 14960256
references.citation: Bull World Health Organ. 2007 Feb;85(2):146-51
references.pmid: 17308736
references.citation: QA Brief. 1999 Jan;8(1):16-9
references.pmid: 12322022
references.citation: Int J Health Care Qual Assur Inc Leadersh Health Serv. 2004;17(7):368-76
references.pmid: 15552392
references.citation: Int J Qual Health Care. 2005 Oct;17(5):391-9
references.pmid: 15951311
references.citation: Health Policy Plan. 2004 Jan;19(1):1-10
references.pmid: 14679280
references.citation: Int J Qual Health Care. 2008 Dec;20(6):375-83
references.pmid: 18799469
references.citation: Lancet. 2005 Mar 5-11;365(9462):864-70
references.pmid: 15752530
references.citation: Health Econ. 2008 Jan;17(1):5-19
references.pmid: 17387710
references.citation: Int J Qual Health Care. 2006 Apr;18(2):134-44
references.pmid: 16423842
references.citation: Health Policy Plan. 2005 Dec;20 Suppl 1:i49-i57
references.pmid: 16306069
references.citation: Bull World Health Organ. 2007 Sep;85(9):712-8
references.pmid: 18026628