Mobile Outreach Health Services for Mothers and Children in Conflict-affected and Remote Areas: A Population-based Study from Afghanistan

Access to care in conflict-affected Afghanistan is challenging; the proportion of pregnant women receiving any antenatal care (ANC) is below 60% nationally, and less than half of infants received all their vaccinations in 2015. In an attempt to reach the most vulnerable women and children, Afghanistan's Ministry of Public Health (MoPH) made mobile health teams (MHTs) part of standard package of health services in 2003. This study sought to assess whether sustained, scheduled MHT services increase ANC, postnatal care (PNC), and childhood immunisation in conflict-affected and remote regions of Afghanistan.

MoPH outreach services include the following: (i) vaccination outreach from clinics to surrounding villages returning to base the same day; (ii) mobile clinics providing adult trauma and non-communicable disease care; and (iii) scheduled service delivery from maternal and child health (MCH) MHTs, designed to reach pregnant women and children under 5 years. The MHTs visit remote villages every 2 months and return to base every 4-8 weeks. A village only receives the services of a MCH-MHT if the travel time to the nearest open health centre by any available transport system is more than 2 hours.

The cross-sectional, population-based study was conducted from March 2013 to March 2017 among 338,796 pregnant women and 1,693,872 children aged under 5 years in 8 provinces of Afghanistan. Fifty-four "intervention districts" received MHT services for 3 years, compared with 56 "control districts" in the same province without any MHT services over the same period. Proportions were compared using multivariable linear regression adjusted for clustering and socio-demographic variables.

Key findings:

• The proportion of pregnant women receiving at least 1 ANC visit was higher in intervention districts (83.6%) than control districts (61.3%) (adjusted mean difference (AMD) 14.8%; 95% confidence interval (CI): 1.6% to 28.0%).
• The proportion of children under 1 year receiving their first dose of measles vaccine was higher in intervention (73.8%) than control districts (57.3%) (AMD 12.8;95% CI: 2.1% to 23.5%).
• Facility delivery, PNC, and pentavalent vaccine coverage were higher in intervention than control districts, though these results did not reach statistical significance.
• MHTs did not increase clinic-level service provision for ANC (AMD 41.32;95% CI: -52.46 to 135.11) or any other outcomes.

Thus, despite increasing levels of conflict across the study area, the researchers found a consistent association between implementation of MHTs and improved coverage of MCH interventions. They note that sustained contact from the same service provider "helps families develop trust and increases demand". Furthermore, repeated visits can enable MHTs to engage with village leaders and local "access negotiators" in conflict-affected areas.

The researchers note that the higher coverage in the intervention areas is most likely attributable to the MHT efforts rather than referrals to clinics. Referral problems in countries like Afghanistan have been found to be due to lack of access to transport, lack of funds, and limited decision making power of women. In Afghanistan, the MoPH and UNICEF are developing cash transfer and mini-ambulance models to assist with referral, but implementation remains challenging.

In conclusion, "progressive financing systems are required as well as recognition that mobile outreach is an essential service and not just an 'optional extra' for the most hard to reach and deprived mothers and children. Robust cost-effectiveness data are also needed."