Ministry of Public Health
Islamic Republic of Afghanistan
Gender Related Barriers to
Access and Utilization
of Primary Health Care Services with
Focus on Access to first level Reproductive Health
and Mental Care Services
Findings, 2009
Gender Related Barriers to Access and Utilization Reproductive Health, Mental Care
Gender Related Barriers to Access and Utilization of Primary
Health Care Services with Focus on Access to First level
Reproductive Health, and Mental Care Services
Findings 2010
Ministry of Public Health
With
UNFPA
Principal Investigator:
Dr Mir Lais Mustafa
Co-Principal Investigator: Dr Sayed Ataullah Saeedzai
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Gender Related Barriers to Access and Utilization Reproductive Health, Mental Care
1 Acronyms
AHS
ANC
APH
BHC
BPHS
CBA
CBHC
CDC
CHC
CHWs
CMWs
CPOs
CPR
CS
DHOs
FGDs
FP
HoHs
HPs
IEC
IMHCS
IRB
IDIs
IDPs
JUH
KAP
LLINs
MMR
MoPH
NBC
NGOs
PHF
PHDs
PHOs
PNC
PPC
PPHDs
RH
RHCS
SHC
SM
STs
TBA
Afghanistan Household Survey
Antenatal Care
Ant Partum Hemorrhage
Basic Health Center
Basic Package of Health of Services
Child Bearing Age
Community-based Health Care
Center for Disease Control and Prevention
Comprehensive Health Centers
Community Health Worker
Community Midwives
Chief Police Offices
Contraceptive Prevalence Rate
Cesarean Section
District Health Officers
Focus Group Discussions
Family Planning
Head of Households
Health Professionals
Information, Education and Communication
Improve Maternal Health Care Services
Institutional Review Board
In-Depth Interviews
Internally Displaced Persons
Johns Hopkins University
Knowledge, Attitudes and Practices
Long lasting Insecticide Nets
Maternal Mortality Ratio
Ministry of Public Health
New Born Care
Non Governmental Organizations
Public Health Facility
Provincial Health Directorate
Provincial Health Offices
Post-Natal Care
Post Partum Care
Provincial Public Health Directorates
Reproductive Health
Reproductive Health Care Services
Sub Health Center
Safe Motherhood
School Teachers
Traditional Birth Attendant
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Gender Related Barriers to Access and Utilization Reproductive Health, Mental Care
TB
MHCS
UNICEF
VLs
WRA
WHO
Tuberculosis
Mental Health Care Services
United Nation Children’s Fund
Village Leaders
Women of Reproductive Age
World Health Organization
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Gender Related Barriers to Access and Utilization Reproductive Health, Mental Care
Table of Contents
1
Acronyms........................................................................................................................................ 2
Table of Contents .................................................................................................................................... 4
Executive Summary ................................................................................................................................. 6
2
Acknowledgement .......................................................................................................................... 9
3
Introduction.................................................................................................................................... 9
3.1
4
Goal .............................................................................................................................................. 11
4.1
5
Gender and Health: Afghanistan.............................................................................................. 9
Objectives: ............................................................................................................................. 11
Methods ....................................................................................................................................... 11
4.1 Quantitative Method: .................................................................................................................. 11
4.2 Qualitative Method:..................................................................................................................... 11
6
5.3
Study Sites: ............................................................................................................................ 12
5.4
Inclusion criteria for selection of target site provinces in Afghanistan:.................................... 12
5.5
Exclusion criteria for selection of target site provinces in Afghanistan: ................................... 12
5.6
Selection steps: ...................................................................................................................... 12
Approaching Research Subjects..................................................................................................... 13
6.1
Tools Development: ............................................................................................................... 14
7
Ethical Issues................................................................................................................................. 14
8
Data Management ........................................................................................................................ 14
9
Data Analysis Plan ......................................................................................................................... 15
4
Gender Related Barriers to Access and Utilization Reproductive Health, Mental Care
8.1 Qualitative data: .......................................................................................................................... 16
9.2
Quantitative data: .................................................................................................................. 16
10
Qualitative Domain ....................................................................................................................... 16
11
Section One .................................................................................................................................. 16
11.1
12
Section Two .................................................................................................................................. 21
12.1
13
Finding of Women Focus Group Discussion (WFGD): .............................................................. 16
Finding of Men Focus Group Discussion (MFGD): ................................................................... 21
Section Three................................................................................................................................ 25
13.1
Finding, In-depth- Interviews, Community Health Workers (CHWs): ....................................... 25
14
Section Four.................................................................................................................................. 27
15
Quantitative Section ..................................................................................................................... 28
15.1
Demographic characteristics, common life style practices ...................................................... 28
15.2
Gender role in decision making related to health problems.................................................... 30
15.3
Gender power and role in decision making............................................................................. 32
16
Conclusions................................................................................................................................... 43
17
Policy Recommendations .............................................................................................................. 44
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Gender Related Barriers to Access and Utilization Reproductive Health, Mental Care
Executive Summary
This study explores gender related barriers to access and utilization of primary health care services with
focus on access to first level reproductive health and mental health care services among women and
men among Pashtun, Tajik and Hazara Uzbek and Turkmen ethnic groups, Community health workers
and District Health Care Providers (DHOs) views were explored on how to improve utilization of primary
health care services at public health facilities. A combination of qualitative and qualitative methodology
was applied to collect information from the key informants through structures questionnaires,
conduction of focus group discussion and in-depth interview. All interviews with key informants were
noted down, transcribed and analyzed, applying constant comparison as well as analytical induction.
The objectives of this research include the followings:

To understand and explore health seeking behaviours of men and women and the underlying
social factors associated with disparities in access to, and use of health care services at the first
primary health care level.

To identify gender-related barriers that may contribute to ineffective use of, and access to
health care services.
In order to explore gender related barriers resulted in ineffective use of health care services and
understand health seeking behaviors among men and women belonging to pashtun, Tajik and Hazara
Uzbek and Turkmen ethnic groups dominant provinces are purposefully selected, then from each
stratum (Pashtun, Tajik and Hazara Uzbek and Turkmen dominant provinces) one province was
randomly selected and at the final stage two health facilities were selected randomly to select key
informants.
Summary Key Findings

Majority of participants have defined health as physical and mental well being; some of
participants have defined health as economic well being. Women have defined someone as a
healthy person, who is happy, fresh, kind , not mentally disturbed “ focus on metal well being”
and, men have defined someone as a healthy person, who is able to work, serve his family and
country and be strong ,fat and not having any body-pain , “focus on physical well being”.

Majority of Hazara women defined health as physical and mental well being. Tajik women defined
health as mental and social well being and Pashtun women defined health as physical well being
and Uzbek and Turkmen women defined health as social and physical well being.
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Gender Related Barriers to Access and Utilization Reproductive Health, Mental Care

Majority of men belonging to Hazara, Tajik and Pashtun, Uzbek and Turkmen ethnic groups have
defined health as physical and mental well being.

The results of this study indicated that majority of people are seeking care from public health
facilities; in case their health are not improving they are seeking care from hospital at capital of
provinces and Kabul. The results of this study indicate that some people are also seeking care from
traditional healers, mullahs and Ziarats (Graveyards). Few participants have mentioned that they
are using herbal medicine, when they get sick. Results of this study indicated that women are
frequently using public health facilities. Men prefer self -medication when they get sick; in case
they are not recovering, they are seeking care from public and private health facilities.

Findings of the study indicated that mental problems are curable. Most of mental health clients
are seeking care from doctors. The results showed that health workers at public health facilities
are not trained to treat mental health problems and there is no medicine in public health facilities
to treat mental health clients, therefore most of clients are seeking care from Hospitals in Kabul.
The results show that some of clients having mental health problems are seeking care from
Mullahs and attending Ziarats as well. The results show that women are more prone to mental
disorders than men. Young male group of people are mentioned to suffer from mental health
disorders as well in Afghanistan. The study findings correlate mental disorders with war, poverty,
and economic problems.
The findings of the study show that there is insufficient capacity to treat mental health disorders
in public health facilities, (lack of psychologist and mental health specialists at public health
facilities and even at provincial hospitals), therefore this phenomenon tend to discourage those
who have mental health disorder to seek care from public health facilities (men of non health
seekers) and make them to seek care from Kabul Hospitals “Ali Abad”.


The results of this research indicated that, mentally ill patients are facing problems, whenever
they wanted to participate in social gatherings and activities. People avoid individuals with mental
disorders. Mental disorders have an adverse effect on people’s wedding, especially if patients are
females.

The results of this study showed head of households, husbands, fathers and brothers are making
decisions for patients to seek care. Focus group discussions with men indicated that, majority of
women don’t have power of decision making.” Their husbands, fathers or (any male member of
family) are making decision for them to seek care. Focus Group Discussions (FGD) results with
women show that, in very few cases husband and wife together make decision to seek care. In
situations where there is no male member of the family at home, only then, women can make
decision to seek care.

The findings of this research have revealed that women, especially among Pashtun ethnic groups
lack the power of decision making to seek health care services. They need to receive permission
either from the head of households, or their husbands. They have to be to be accompanied by a
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Gender Related Barriers to Access and Utilization Reproductive Health, Mental Care
mahram (male member of the family) while they are seeking care from public health facilities.

Characteristics attributed to good health workers are: health workers being kind with patients, not
having discrimination, having the sense of serving people, competent, skilled and knowledgeable.
Health workers should treat people properly, keep what have been discussed with him/her
confidential, provide quality medicine to patient, and encourage people to attend health facilities,
provide vaccines to people and pass community problems to ministry of public health.

Results of this research indicated the following suggestions to improve utilization of health
services at public health facilities:
recruiting qualified staff , especially female staff, ensure availability of health services in 24 hours
to people, availability of quality drug and avoidance of drug stock out in public health facilities,
training health workers on medical ethics and code of conducts, provision of transportations and
ambulances at the public health facilities, conduct health education sessions, doctors should
spend more time with patients during observing them; conducting regular meetings with health
facility staff to discuss problems transferring to health facilities from community. Discuss the
problems with community elders and involving them in the process of decision making; keep the
health facility clean, encourage people to vaccinate their children, behave compassionately with
patients.

Results of this research show that, health staff’s harsh behavior at public health facilities, non
availability of medicine at public health facilities, lack of transportations, suboptimal trust of
clients on health worker’s skill and knowledge, non availability of female staff, non availability of
24 hours of services at the public health facilities, and lack of women’s decision making power are
major barriers to seek health care.

Lack of availability of 24 hours of health care services was mentioned by both women and men
group of non health seekers even by health seekers groups as a barrier to seek care from public
health facilities.

Shortage of medical supplies and equipments and drug stock out in some of the public health
facilities are mentioned causes of sub-optimal utilization for all study groups.

Poor economic status of people results in their inability to afford the burden of transportation
cost; this was mentioned as barriers for both men and women of non health seeker groups
especially in hard to reach areas.

Lack of trust of people on skills and knowledge of health workers in public health facilities have
made the people seek care from private doctors or going to Kabul to seek care. This has lead to
under utilization of public health facilities in their living areas.
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Gender Related Barriers to Access and Utilization Reproductive Health, Mental Care
2 Acknowledgement
Ministry of Public Health, Research Department would like to seize the opportunity to thank UNFPA for
their generous supports to make this research on Gender Related Barriers to Access and Utilization of
Primary Health Care Services with Focus on Access to First level Reproductive Health, Mental Health
Care possible. We extend our gratitude to all members of the research team who undertook
considerable efforts and struggles to obtain the required information to assist stakeholders in health
sector to make evidence based and actionable decisions. We highly admire the research participants
men and women from all sects under study Pashtun, Tajik, Hazara, Uzbek and Turkmen and Community
Health Workers (CHW) for their valuable contributions to obtain information on their perceptions,
behaviors and practices on Gender Related Barriers to Access and Utilization of Primary Health Care
Services with Focus on Access to First level Reproductive Health and Mental Care in Afghanistan. We
also appreciate the efforts of Governor Offices, law and order agencies (chief of police), Municipalities,
Provincial Health Directorates and NGOs particularly in 4 provinces (Logar, Badakhshan, Baghlan and
Faryab Provinces) for enabling the study teams to carry out their meticulous work.
We thank Dr Haseeb Niayesh who has helped us in data analysis and report writing.
3 Introduction
3.1 Gender and Health: Afghanistan
Afghanistan is a patriarchal society repeatedly under strain from decades of conflict. Since 2002 actions
have accelerated to build the health infrastructure largely through donor provision of the Basic Provision
Health Services (BPHS) in many provinces throughout Afghanistan. Approximately 77% of the
population of Afghanistan was estimated to be covered by the BPHS in 2004 however, problems of
access to the health facilities still abound with nearly 80% of Afghans living in rural areas and lacking
necessary roads and transportation to consult health providers before illness progresses too far. This is
of particular concern for maternal health. Afghanistan has a maternal mortality rate of 1600 per
100,000 live births and in some of the worst of provinces, such as Badakhshan, the maternal mortality
rate has been estimated as high as 6500 per 100,000 live births. In fact, women have been projected to
die three times as much from maternal complications than from other causes. Afghan women face
double jeopardy in securing their rights to health because of poor health infrastructure on the one hand
and gender norms that place barriers on their access to health care on the other.
While women are in a better situation since the Afghan Constitution passed in 2004 which guaranteed
equal rights for all, Afghanistan still remains a strongly enforced patriarchal society. In strongly enforced
patriarchal contexts, women are often socially, culturally and economically dependent on men. Women
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Gender Related Barriers to Access and Utilization Reproductive Health, Mental Care
have restricted roles in making decisions and are not able to move from their homes without permission
and in many cases without chaperones. Bartlett et all found in a study of maternal mortality carried out
in 4 provinces in Afghanistan that male relatives needed to give permission before a pregnant woman
could seek health care. It was also found in the same study that the more rural and remote the
community, the more restricted the women’s mobility and access to information.
This project seeks to inform key stakeholders in primary health care delivery in Afghanistan on the
gender influences of health seeking behavior, with particular focus on reproductive health, and mental
health, behavioral patterns, in an attempt to promote gender responsive elements in health policies and
programs. In the context of Afghanistan, the level of intervention is focused on basic health care centers
and their catchment areas, including both health and non health seekers.
While access to all BPHS will be investigated, particular focus will be given to first level services in
reproductive health, and mental health. Lack of utilization of reproductive health services and
insufficient health literacy of obstetric complications contribute to high rates of maternal mortality.
Regarding mental health, recognition is increasing of service gaps in provision of psychosocial/mental
health services in Afghanistan. In order to ensure that reproductive health and mental health at the
primary health care facilities are being optimally utilized, it is necessary to investigate the related health
seeking behavior patterns of men and women in Afghanistan and identify any access barriers
Appropriate access to health care and the use of these services are crucial factors in determining
positive health outcomes. Consistent research results outline the following factors of health seeking
behaviors (HSB): socio-economic status (i.e., household poverty and levels of education), proximity to
health facilities, type, duration and perceived severity of illness and long waiting times, inadequate or
negative staff attitudes adequate health education as well as sex and gender Restrictions on the
physical mobility of women ("gate-keeping"), restrictions on women's decision-making, mobility and
autonomy interact with the above factors to produce increased obstacles for women to effectively
access and use existing health care services. HSB differences between men and women generally
reflect that men delay seeking health care for longer but use trained medical services directly while
women tend to practice "self-care" or use traditional medicine before seeking trained medical care Yet,
for certain conditions, it has been shown that women seek more health services than men - though
these services are often of poorer quality and at lesser expense than trained medical care. Geographic
location, illness severity and higher socioeconomic status were found to influence men's HSB while
lower user fees, shorter duration of illness and fear of social isolation were associated with women's
HSB The social determinants of health that underpin these different patterns of HSB, as well as how
these determinants affect health equity differ from one setting to another.
While sex (biological differences) has important impacts upon women’s and men’s different
susceptibilities to disease and ill health, socially constructed differences and inequalities between
women and men (gender) affect their access to and control over material and non-material resources,
decision-making power in the family, household and community, and their roles and responsibilities in
society, all of which impact on their ability to protect their health. Gender norms also shape institutions,
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Gender Related Barriers to Access and Utilization Reproductive Health, Mental Care
including the health sector In turn, these influence women's and men's exposure to health risks, access
to health information and services, health outcomes, health care response and the social and economic
consequences of disease and ill-health.
4 Goal
The goal of study was to perform a gender assessment of health-seeking behavior and access to first
level health services including reproductive health and mental health in Afghanistan. This is in order to
understand how gender differences in access and utilization of health care by women and men may
contribute to inequitable health outcomes.
4.1 Objectives:

To understand and explore health seeking behaviours of men and women and the underlying
social factors associated with disparities in access to, and use of health care services at the first
primary health care level.

To identify gender-related barriers that may contribute to ineffective use of, and access to
health care services.
5 Methods
In order to achieve the objectives of the study, we designed both quantitative and qualitative method.
4.1 Quantitative Method:
This part of study consist of structured questionnaire which was administered to service providers
(doctors, supervisors, midwifes, and vaccinators), health care seekers and non health seekers. The
questionnaire for health care providers contained three sections, socio demographic, training and
professional experience, and health services and health perceptions. The questionnaire for health care
seekers consisted of socio demographic, access and utilization of health care.
4.2 Qualitative Method:
This part of study consisted of in depth interviews with district health coordinators and community
health workers. Similarly focus group discussions were conducted within each clinic area, one with male
group and one with females. In the in depth interviews, questions regarding professional experience,
community health issue and health service provision were probed. Similarly in focus group discussion,
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Gender Related Barriers to Access and Utilization Reproductive Health, Mental Care
we probed the perceptions of health care seekers and non seekers on what is health, what are their
health seeking behaviors and what is health care provision from their standpoint.
5.3 Study Sites:
Site selection criteria were prioritized according to ethnic representation in order to ensure that
different behavioral patterns influenced by traditions of ethnic groups are reflected. The objective was
to generate information that will enable the Afghanistan health sector to strategically target health
services to meet the needs of its diverse population groups. While there are varied ethnicities in
Afghanistan (Tajik, Pashtun, Hazara, Uzbek, Turkmen, Aimak, Baloch, Pashia, Hindu Sikh, and Gujar), the
focus was Tajik, Pashtun, Hazara, Uzbek, Turkmen groups because they have the largest representation.
5.4 Inclusion criteria for selection of target site provinces in Afghanistan:
1. Majority presence/clustering of one of the predominant ethnicities: Tajik, Pashtun,
Hazara,
Uzbek, Turkmen.
2. Presence of a district exclusively or predominantly urban comprising the targeted ethnicity
3. Presence of a district exclusively or predominantly rural comprising the targeted ethnicity
4. Adequate existing infrastructure to support the conduct of the survey (i.e., existence of roads,
public facilities)
5. Availability of Medical Officer (MO) at the health facility
5.5 Exclusion criteria for selection of target site provinces in Afghanistan:
1.
2.
3.
4.
Provinces with security risks that prevent safe access of the field research team
District not available with exclusively or predominantly urban composition
District not available with exclusively or predominantly rural composition
Inadequate existing infrastructure to support the conduct of the gender assessment (i.e.,
existence of roads, public facilities)
5. Lack of availability of Medical Officer (MO) at the health facilities
5.6 Selection steps:
1. Study was performed in four provinces, i.e. Badakhshan, Logar, Baghlan and faryab
2. We got list of all districts from the four selected provinces (information were obtained from the
Central Statistics Office and the MoPH).
3. We eliminated districts with security risks that prevent safe access of the field research team
4. We eliminated districts with inadequate existing infrastructure to support the conduct of the
gender assessment
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Gender Related Barriers to Access and Utilization Reproductive Health, Mental Care
5. We divided the remaining districts in each province by urban and rural composition. There were
two lists for each province.
6. We randomly selected one district from the urban list and one from the rural list for each province.
7. We obtained the list of all primary health facilities in each of the selected districts from HMIS
department of MoPH
8. We eliminated all primary health facilities with incomplete staffing.
9. We ensured remaining primary health facilities have catchment areas that include clustering of the
ethnic group for which the province was selected
10. We randomly selected one primary health facility from the final list of urban district facilities and
from the final list of rural district facilities for each province. There were 8 health facilities selected
in total.
Sample Size:
The total sample size was 636 health care seekers (people who were visiting health facility) and non
health care Seekers (the individuals for community). The total interviewed health care providers were 81
persons from all four provinces.
6 Approaching Research Subjects
A. Provincial Level:
Permission letter was taken from MoPH. The Provincial Health Director was approached and the study
purpose plus methodology was explained. His point of view regarding selected urban and rural districts
and selected functional BHC was sorted and if there is some reservation the plan may be reviewed per
Director's advice.
B. District Level:
At the district level, the district health coordinator was approached and the project has been explained.
The functioning of selected BHCs was discussed. The local Government authorities were met with the
help of health Coordinator and the question of security for the team was discussed and ensured. The
district Health Coordinator informed the BHC staffs of the team visit.
C. BHC Level:
A joint meeting of all health care providers at the selected BHC including CHWs was conducted and the
project was thoroughly explained and their view point regarding conduction of study and subject
approach at the BHC and community level was sorted out. With the help of BHC staffs, we identified
community leaders, mullahs, members of the national solidarity programs, shurah e sehai and influential
people. We met them in a joint gathering where the purposes and methods of study were explained. For
FGDs with Health care seekers 8 to 10 persons among females and 8 to 10 persons among males who
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Gender Related Barriers to Access and Utilization Reproductive Health, Mental Care
attended and use the BHC services were identified at BHC.The structured questionnaire was
administered to health care providers after consent given at separate room in BHC after OPD is over. For
maintaining privacy, there was no other person in the room except the interviewee and interviewer. For
female health care providers the interviewers were female research officers.
For the health care seekers, there were twenty questionnaires 10 for male and 10 for female. After
knowing the number of OPD per day we decided whether to recruit the seekers in a systematic
randomly manner or saturation point approach. The questionnaire was administered after oral consent
read and participants totally understood the purpose of the study, benefits and risk involved in
participation, compensation, voluntary participation, withdrawal option at any time without affecting
their treatment facilities.
Two villages were randomly selected from each catchment area of BHC. Ten male and ten females were
interviewed from one randomly selected village, twenty households were randomly selected from the
selected village.
6.1 Tools Development:
Five questionnaires have been developed for health care providers and health care seekers as shown in
the above table for sample size. It is initially developed in English and later on translated into local
languages Dari and Pashtu. For validity checkup it has been translated back to English. Moreover, two
interview guides for district health coordinator and community health workers and FGds guide for
health care seekers and non health care seekers have been developed.
7 Ethical Issues
The project was submitted to Institutional Review Board Ministry of Public Health for clearance and
approval was obtained. We ensured the confidentiality of data right from data collection till the data
entry and analysis. Nobody had access to instruments and data except project core team. The
instrument was locked in cabinet and data was protected in the computer with a password. We ensured
privacy during interview and the taped voices were destroyed after transcription is over. Consent was
taken before conducting interviews, FGDS and structured questionnaires.
8 Data Management
Four teams were recruited one for each province, each team comprised of one team leader, 2 male data
collectors and 2 female data collectors. The instruments were field tested in the areas with three ethnic
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Gender Related Barriers to Access and Utilization Reproductive Health, Mental Care
dominant communities where the survey was not being conducted. Comprehensive data quality control
measures were taught to all members of visiting team. The filled structured instruments were checked
on spot by the data collectors and then by supervisors for inconsistencies, missing information, incorrect
responses and appropriate corrective action was taken instantly. For qualitative part comprehensive
guide had been developed which ensured quality. In addition to field check up for inconsistencies the
team met at the end of each data collection day and recheck for the problem they encounter during
quantitative and qualitative data collection and if there was mistake then they went back to field for
clarification. The structured questionnaires were locked in a box after thorough checkups and were
transferred to Central office with the team.
The qualitative data (audio tapped) was transcribed and compiled carefully word by word without
changing the structure of the sentence and was compared with the notes taken at the end of data
collection day. Moderator and note taker examined the notes and transcripts in order to have
unanimous perception of the phrases and words recorded. Additional comments from moderator,
note-taker was recorded separately with each transcribed data record. In addition to the above
mentioned data quality controlling measures, the project core team randomly spot checked to ensure
the quality of data collection and re administer the questionnaires for validity.
9 Data Analysis Plan
The following variables were measured through qualitative and quantitative analysis:







A description of the underlying social dynamics that negatively impact health outcomes
for men and women.
Identification of gender issues that provide barriers to optimal first level health care
access and utilization by women and men.
Assessment of gender differentials in reasons for consultation delay at first level healthcare facilities.
Assessment of gender differentials in medical complaints presented at first level health
care facilities.
Assessment of gender differentials influencing attendance and utilization of primary
health care.
Identification of emerging themes or areas of importance on gender differences in health
care seeking behaviour by men and women.
Identification of gaps between first level health services and community needs expressed
(for both women and men).
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Gender Related Barriers to Access and Utilization Reproductive Health, Mental Care
8.1 Qualitative data:
Findings from different sections of the study was triangulated and synthesized to form a coherent
picture of existing knowledge, attitude and practices among male and females’ health seeking
behaviours. Qualitative analysis was done through the development of thematic codes from Focus group
discussions and in-depth interviews and was analyzed by using manual method.
9.2 Quantitative data:
Data was entered in Epidata software 3.1. The analysis was performed using SPSS version 17.
Descriptive analysis of each variable was done segregated by sex to show gender differences. Data was
compared between male and female and chi-square and student t-test will be applied as per type of
data.
10 Qualitative Domain
Health seeking behaviors and perception of women and men belonging to Pashtun, Tajik, Hazara, Uzbek
and Turkmen ethnic groups and community health workers.
11 Section One
11.1 Finding of Women Focus Group Discussion (WFGD):
(I). Health seeking behaviors, and Perceptions on Gender Related Barriers to
Access and Utilization of Primary Level Reproductive Health, Mental care
among Women of Pashtun, Tajik, Hazara, Uzbek and Turkmen Ethnic
Groups in Afghanistan
The perception of most of women of pashtun ethnic group on health, and healthy person are as
following;

Healthy person is someone who is active, able to work, serves his/her family and country.
Healthy person seems active, happy, fresh, and clean.

Healthy person seems cooperative, behaving well and pleasantly and always tries to assist
his/her family and people.
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Gender Related Barriers to Access and Utilization Reproductive Health, Mental Care
“Health is wealth, FGD among women of
pashtun ethnic group in Logar province”
The perceptions of women of Tajik ethnic groups on health and being healthy are:
 Someone who does his/her work, seems fresh, fat and happy and active, healthy person is able
to grow up his/her children well and educated, works with lots of enthusiasm and energy and
carry out his/her all activities well.
Women of Hazara ethnic groups perceive health/healthy person and being healthy is as:
 Healthy person someone who is fat, peaceful, well, not having any physical problems, seems
pleasant and smiling. Someone who does not have any body pain, mental problem and
economical problem.
 Healthy person does his/her activities, grow up and educate his/her children, participate in
household chores and demonstrate a lot of patience and tolerance in his/her life.
Women of Uzbek and Turkmen ethnic group think health/being healthy and healthy persons to be as:

Being healthy is, having pleasant and happy life, not having any problems in life, able to work,
not having any physical pain. Healthy person is someone who is happy, and able to work, having
good appetite, and actively participate in household chores.
“Being healthy means having peace in life, being comfortable
and having peaceful life, FGD Imam Sahib village”
Majority of women of Pashtun ethnic groups stated that they get care from local doctors once they get
ill. Some of them are seeking self medications
and few of them have mentioned that
they are staying at home when they
“If we get sick no one is at home to take us to
get sick, because they don’t have any one
doctor, FGD with women of pashtun ethnic group
at home to take them to doctors.
in Logar province”.
Majority of women of Tajik ethnic groups expressed that they get treatment from the nearest public
health facilities. If they are not recovered then the next option is the nearest hospital where they will
get treatment. Few of them are seeking care from religious leaders as well.
Majority of women of Hazara ethnic groups have mentioned that in case they get sick, if they have
money they will go to private doctors, if they don’t have, then they will go to public health facilities, few
of them have mentioned that they are seeking care from Mullahs in case they are sick.
17
Gender Related Barriers to Access and Utilization Reproductive Health, Mental Care
Health seeking behaviors of women of Uzbek/Turkmen ethnic groups showed that they are seeking care
from public health facilities, private doctors, hospitals and mullahs. In few cases they are seeking care
from private pharmacist or using medicine available at home.
Tajik women are also getting treatment from local quacks advising them “qishlaqi Dawa” drug available
locally”.
Regarding the mental health treatment, the various ethnic groups expressed their perceptions as:

Majority of pashtun women take their patients to ziarat (Graveyards of Saints) and mullahs,
while few of the mentally ill individuals are taken to qualified doctor.

Majority of Tajik women believe that mentally ill person should be taken to mullahs for
treatment. Some said they should be treated in hospitals while some expressed they do nothing
with the mentally disordered persons and God will recover them.

Majority of women belonging to Hazara ethnic group are taking their mentally ill relatives to
provincial hospital. Some believe that Mullah can treat their patients while at extreme they take
their patients either to Kabul or Pakistan

Majority of women of Uzbek/Turkmen have mentioned that, they are keeping mentally ill
person at home and take them to nowhere.
On getting the perception of the women whither mental disorders are curable or not, they pointed out
as

Majority of Tajik women believed that mentally sick person can be treated, provided that he/she
is treated properly.

Majority of women of Hazara ethnic group believed that mental disordered person is curable;
some of them believed that they are curable only if they are fed well, taken care and treated
properly.

Women of Uzbek and Turkmen believe that mentally ill person is treatable, only if they have
money.
On inquiring the reasons for getting mental health disorders the various groups expressed their views
as:
 Women of Pashtun ethnicity have mentioned that, those who do not have children, having
economic problems, have lost their family members and women whose husband behave them
harshly are more prone to mental disorders. Some of them mentioned that they did not have
any information in this regards
18
Gender Related Barriers to Access and Utilization Reproductive Health, Mental Care

Women of Tajik ethnic group believed that those who have Mergee (epilepsy) are more prone
to mental disorders.

Women of Hazara ethnic group believed that, poor economic status, being away from family
members, being upset and weather can cause mental disorders.

Women of Uzbek/Turkmen ethnic group have mentioned that they don’t have any information
in this regards.
Inquiring the social interactions of the mentally ill people:

Majority of women of Pashtun ethnic group believed that people with mental disorders should
be blend with the society, be part of the society, people should behave them well and not keep
them isolated. Few of them believed that they should not be part of society and be kept isolated
This group had split ideas on impact of mental disorder on weddings, some believed that
mentally ill persons should not get marry, others believed if they get marry , they will be happy
and gradually they will recover. They also said that they have seen men and women both had
such problems; people were laughing at them, throwing stone at them and did not let them
participate in social gatherings.
“Person with mental disorder
should not participate in
weddings, women FGD,
Badakhshan province, Faizabad
District, Hisari Village”.

The Tajik women believed that People with mental disorders should not participate in social
gathering and it is difficult for them to participate in social events, while others believed that
they should participate and be a part of society. They believed that nobody will marry them.
They should not get married. “In our village there are a lot of people with such problems,
nobody is willing to marry them.”

Most of the Hazara women expressed that mentally disordered people should not /cannot
participate in social gathering and social events. They thought mentally ill person should not get
married, this disease has bad effect on wedding, and nobody is ready to marry a mentally ill girl.
Most of such people in our village encounter the same problems.
19
Gender Related Barriers to Access and Utilization Reproductive Health, Mental Care

Majority of women of Uzbek and Turkmen ethnicity believed that mentally ill people should not
participate in social gatherings; some of them believed that they should participate in social
gathering. They believed that mental disorders have negative effects on weddings and they
should not get marry, because they don’t know their family members. Some participants stated
that most of mentally ill people in their village cannot work, are very poor, nobody is helping
them and nobody is willing to marry them.
(II)
Perceptions on Decision Making Practices at household level to
Access and Utilization of Primary Level Reproductive Health, Mental
care among Women of Pashtun, Tajik, Hazara, Uzbek and Turkmen
Ethnic Groups in Afghanistan

Majority of women of Pashtun ethnic group have mentioned that in case there is a patient at
home , head of household, husband, father, brother decide to take them to public health
facilities, hospitals and mullahs. Few women have mentioned that they themselves along with
their sons decide where to take a patient.

Majority of women of Tajik ethnic group have mentioned that male family members (father,
husband, grandfather) decide in case there is a patient at home to take them to hospitals, public
health facilities and sometimes to mullahs. Only in few cases, it is said that women decide.

Most of women of Hazara ethnic group believed that father/mother and husband/wife together
decide about the fate of the patients.

Uzbek and Turkmen women have expressed that it is the husband, father and father-in law and
mother in law who decide the fate of patients.
(III)
Perceptions on Characteristics and Behaviors of Health Providers
among Women of Tajik, Hazara, Uzbek and Turkmen Ethnic Group
in Afghanistan

Pashtun women were of the view that a good health worker is someone who behaves well, treat
patients properly, listen to the problems of patients, give drug to patients, provide counselling
to patients and assist patients.

Tajik women believed that a good health worker is the one who gives quality drug, injection,
Infusions to patient and do not misbehave with the patients. They also believed that a good
health workers always check blood pressure, and listen carefully to patients’ complains.

Hazara women perceived that a good health care provider is the one who listens to complains of
patients carefully, gives best drug, does not humiliate patients, and does not delay the
treatment of patients in the clinic.
20
Gender Related Barriers to Access and Utilization Reproductive Health, Mental Care

Uzbek and Turkmen women believed that a good health care provider is someone who is
attentive to patients, properly treat patients, be sympathetic to poor, having good professional
qualifications, check patients on their turns, and behave and talk nicely with patients
(IV)
Perceptions on How to Improve Public Health Facilities and Quality
of Health Care at Public Health Facilities

Pashtun women suggest that health workers should behave nicely, make the drug available at
public health facilities, properly treat patients, should be punctual and on time and be
sympathetic with patients.

Tajik women believe that improvement can be achieved in the health facilities if health care
providers serve their villagers, assist their people, refer pregnant women to hospitals, properly
treat patients and refer emergency patients to hospitals with sincerity and dedications.

Hazara women suggest that improvement can be achieved in the health facilities if health
workers treat patients properly, listen to patients carefully, behave nicely with patients, and
provide tablet and injections to patients.

Uzbek and Turkmen women believed that the system can be improved if providers behave with
the people nice and pleasantly, serve people, being attentive to patients, provide good drug to
patients, demonstrate sympathy to patients and work day and night to treat the patients.
12 Section Two
12.1 Finding of Men Focus Group Discussion (MFGD):
(I). Health seeking behaviors, and Perceptions on Gender Related Barriers to
Access and Utilization of Primary Level Reproductive Health, Mental care
among Men of Pashtun, Tajik, Hazara, Uzbek and Turkmen Ethnic Groups
in Afghanistan

Men belonging to Pashtun ethnicity believe being healthy means physical and mental well
being; it is a process that someone can perform physical activities, someone who is able to work,
not having body pain and having strong body and be wise.
21
Gender Related Barriers to Access and Utilization Reproductive Health, Mental Care
“Healthy person is wise person FGD
among men of pahstun ethnic group in

The participant from the Tajik ethnic groups stated that being healthy means free of any
diseases, being strong, peaceful. Healthy man can accomplish all his daily activities, being rich,
able to eat, drink and perform all his social activities. Someone who is fat, active, and
hardworking. Healthy person seems fresh, clean and strong. Healthy person is not complaining
of being sick.
“Health is beyond and above everything, being clever is
being healthy FGD among men of hazara ethnic group “

Men belonging to Hazara tribe believed that healthy person is someone who is happy,
hardworking, free of any concerns, fat, and able to work in the field. Healthy person is thinking
positively, perceiving things optimistically, and behave pleasantly.
“Sick person is not able to work, always he/she is resting He
seems different in term of thinking and physical appearance
FGD among men of uzbeck/turkmen ethnic group “

Participants from the Uzbek and Turkmen ethnic group expressed that being healthy means
being comfortable and at ease, and a healthy person is active as a deer. Healthy person can
perform all his tasks and activities; healthy person is someone who is free of any mental and
physical illnesses. Health person can offer his/her prayers.
The health seeking behavior of various ethnic groups are analyzed as follows:
22
Gender Related Barriers to Access and Utilization Reproductive Health, Mental Care

Majority of men of pashtun ethnic groups said that they prefer self-medication initially, later
from the health facilities close to their residence and then from the private practitioners. Few
participants were getting treatment from CHWs initially and if serious then they were referred
by CHWs to health facilities.

The Tajik participants were of the view that they take medicine available at home initially, if not
from the nearest shops. Some of them used to take care from the traditional healers. They
were also using nearby public health facilities. For complicated problems they utilize nearby
hospitals too.

Men belonging to Hazara tribe said that they get treatment from the nearby private clinic
initially and later from the health facilities and if further care required from the nearby hospital
in the area.

Most Uzbek/Turkmen participants said that they seek care from mullah initially. Some of them
used to seek care from public health facilities and hospitals. While few mentioned that they
prefer self medication initially. Very few mentioned that they prefer to stay home without going
anywhere or getting any medication initially.
On probing where they take their mentally ill individual different ethnic groups stated as below:

Majority of the Pashtun were of the opinion that they take their mentally ill individuals to public
health facilities for treatment. Some of them said they take their patient to Ziarat and Mullahs.
Most of them mentioned that finally they take their patients to Kabul if they are not recovered.
“We take mentally ill person to
akhund who could recite qaseeda
(recite religious song, FGD Hisari
village, Badakhshan province “

Most of the Tajik men believed that mentally ill individuals should be taken to mullah/religious
leaders (akhund), for Dam (prayers). Some were of the view that they should seek care from
public health facilities and hospitals.
23
Gender Related Barriers to Access and Utilization Reproductive Health, Mental Care

Majority of men belonging to Hazara ethnic group were of the view that they prefer to consult
psychiatrists but there are no specialist available in their areas therefore they take their
mentally ill patients to provincial hospital and later Kabul hospitals.

Uzbek/Turkmen were of the view that mentally ill individuals should be taken to mullahs and
Ziarrat for treatment. Few mentioned that doctors should be consulted.
On inquiring if mentally disorders are curable, all the groups were of the opinion that mental disorders
are curable and treatable if proper attention is focused.
(II)
Perceptions on Decision Making Practices at household level to
Access and Utilization of Primary Level Reproductive Health, Mental
care among men of Pashtun, Tajik, Hazara, Uzbek and Turkmen
Ethnic Groups in Afghanistan

Majority of pashtun as well as Tajik men were of the view that it is the head of the household
(father, brother, husband) who decide about the fate of the patient. They said if male elders are
not at home then it is the elder females who decide. It is the men who decide for all members
of the family.

Men belonging to Hazara ethnic group were of the opinion that it is them self along with their
fathers who decide where to take the patients. Some mentioned that occasionally it is the
husband and wife that sometimes decide for the type of care they seek.

Uzbek and Turkmen men said that it is the head of the household, husband, brother or father
who decide the fate of all patients at home.
(III)
Perceptions on Characteristics and Behaviors of Health Providers
among men of Pashtun, Tajik, Hazara, Uzbek and Turkmen Ethnic
Group in Afghanistan

Pashtun men were of the view that a good health provider is the one who treat patients
properly, behave well, be sympathetic and compassionate and give priority to emergency cases.

The Tajik participants were of the opinion that a good health care provider is the one who
diagnose and treat his/her patients properly. A good doctor is kind, behave well, and provide
the best drug to his/her patients.
24
Gender Related Barriers to Access and Utilization Reproductive Health, Mental Care

Men belonging to Hazara group were of the view that a good health care provider is the one
who listen to patient’s complain, give quality drug, does not humiliate the patients, does not
delay in management of patients in the clinic.

Most of the Uzbek and Turkmen participants said that a good health provider is the one who
behave kindly with his/her patients, provide best drugs, treat on priority basis those patients
who are suffering from emergency problems, does not refer patients to private pharmacies,
and counsel with patients regarding the diseases.
(IV)
Perceptions on How to Improve Public Health Facilities and Quality
of Health Care at Public Health Facilities

The pashtun men suggested that improvement can be achieved if people are encouraged to
use facilities, conduct health promotion as well as awareness programs, propagate hygiene
messages both at the facility as well as community levels. In addition, providers must learn
medical ethics and be kind and sympathetic with the patients.

The Tajik participants suggested that treating poor and rich equally, providing drugs and
equipments to the health facilities, behaving well with the patients, treating and diagnosing
patients properly and accurately and providing the clinics with regular supplies would
contribute in improvement of the facilities.

Hazara men were of the view that improvements can be brought about if Government
deploy more health workers especially female doctors and midwives, maintain regular
supplies for health facilities, HF should be open for 24 hours, make sure availability of
ambulances, health workers should behave nicely with patients.

The Uzbek/Turkmen participants were of the view that improvement can be achieved if the
centres have vaccination facility, have regular supplies of drugs and necessary equipment.
Moreover, qualified midwifes and doctors should be recruited for each facility.
13 Section Three
13.1 Finding, In-depth- Interviews, Community Health Workers (CHWs):
A1) Professional Training and Working Experience
The following points have been extracted from the in depth interview with the CHWs in the pashtun
dominated areas:
25
Gender Related Barriers to Access and Utilization Reproductive Health, Mental Care







They had experience working in their communities from 1 to 4 years.
They have received training from the nearby health facility on managing diarrhoea, malaria,
worms and family planning.
Most of them received refresher courses on the management of the above mentioned
conditions but few did not.
They were of view that there is need for training on seasonal diseases, ARI and TB and ANC.
They refer the complicated cases to BHC
Some of the complicated conditions are delayed labour, reproductive problems and TB.
Most of the CHWs were happy working with their communities.
“if people are happy with us we
are also happy with people ,Logar
provinces, Mohammed Aghan
district , mughal khail village , indepth interview with CHW”
B1) Issues Related to Community Health (Utilization and Barriers to Seek Health Care
Services)
The in depth interview has underlined the following issues:







Most of the people are using BHCs while some are using private clinic.
Non availability of drugs, lack of female staffs, lack of ambulance, transportation problems are
the main reasons stated by CHWs for under utilization of BHCs.
It was found that men and women have different health problems, disabilities, injuries, trauma,
TB, mental problems, diarrhoea are the health problems faced by men while malnutrition,
anaemia, malaria, hypertension, gynea and obstetrical conditions are the main problems faced
by women as stated by CHWs.
One of the main needs pinpointed for women is the presence of female health care providers as
women do not like to consult male staffs.
The main decision makers at home are fathers, brothers, mothers and in some cases both
husband and wives.
Findings of the study show that head of households “father, brother, mother and in some
families both husband and wives are making decisions.
In order to improve the health care provision, deployment of female staffs, separate waiting
space for females, regular supplies of essential goods for HF, 24 hours service at the facilities are
some of the suggestions given by interviewees.
26
Gender Related Barriers to Access and Utilization Reproductive Health, Mental Care

In order to improve community based health care program, provision of incentives to CHWs,
conduction of refresher trainings, and regular supply of drug and supplies to CHWs will be
crucial.
14 Section Four
Findings, In-depth-Interviews, District Health Officers (DHOs)
A1) Professional Training and Working Experience, Role and Responsibilities
The key issues found during in depth interviews with the district health officers are given as below:
 Most of the district health officers have been working for the last 3 years and they were trained
in health information management, reproductive health services, immunization, and
management.
 The main responsibilities of the DHOs are to coordinate health service provision at the district
level. They are the member of panel for the recruitment of the local medical staffs but do not
have role in their hiring and firing. They coordinate activities like NIDs, inspect local
pharmacies, monitor the activities of health facilities, and coordinate with other line
departments and implementing NGOs.
B1) Health Services Utilization and Barriers to Seek Health Care Services
The findings regarding the utilization of the health services are given below:
 DHOs were of the opinion that majority of people use the health facilities. Those who do not use
believe in alternative care like self medication, consulting mullahs, going to ziarats. Some of
them are afraid of vaccines, harming their children.
 It was found that women are utilizing health facilities frequently as compared with the men
 The DHOs were of the view that head of the household are the main decision makers on all
issues particularly health. In addition mother in laws also play critical roles for the health
related problems of their daughter in laws.
 The DHOs were of the opinion that deployment of midwifes, 24 hours service at the facility,
provision of necessary supplies on regular basis, continuous education of medical staffs,
provision of health promotion measures would be key in improvement of health facilities.
27
Gender Related Barriers to Access and Utilization Reproductive Health, Mental Care
15 Quantitative Section
The quantitative part of the study consisted of structured questionnaire which was administered to service providers (doctors, supervisors,
midwifes, and vaccinators), health care seekers and non health seekers. The questionnaire for health care providers contained three sections,
socio demographic, training and professional experience, and health services and health perceptions. The questionnaire for health care seekers
and non seekers consisted of socio demographic, access and utilization of health care.
Health care seekers and none seekers:
This part of the study explored statistics on demographic characteristics of study participants such as age, sex marital status, sources of energy
and life style and patterns. In addition the health seeking behaviors and major barrier to seek care while encountering health problems.
This study mainly focus on gender barriers to seek care and role and power of women to make decision in health related issues and problems
15.1 Demographic characteristics, common life style practices
The study shows that majority of study participants were relatively young. 53% of male participant’s age ranges from 15 years to 35 years, while
73% of female participant’s age ranges from 15 year to 35 years. The results show that with increasing age of participants, the sample of
participants skews toward male. In addition 83% of male participants in the study sample were married while 16% were unmarried, among
female participants 85% were married and 10% unmarried. 4% of the female participants were widows. It was found that majority of ethnic
groups were using traditional pit latrine, 77% of male participants and 77% of female participants are using traditional pit latrines.
85% of male participants have mentioned that the latrine is located inside the compound of their houses and 86% of female participants have
mentioned that latrines located inside the compound of their houses.
The study shows that 28% of male participants have mentioned electricity as the main source of lighting , 15% of them have mentioned
generator as main source of lighting, 26% of them have mentioned gas lamps is the main source of electricity, 22% indicated kerosene oil lamp
as main source of lighting inside their households.
Major sources of water were found to be hand pumps, covered wells, open wells, river, stream and lakes. For the detail refer to Table 1
28
Gender Related Barriers to Access and Utilization Reproductive Health, Mental Care
Table 1
Variable
Name
Age
Marital status
Type of toilet
Latrine located
within
compound of the
house hold
Main source of
lighting in the
household
Description
15-25
26-35
36-45
46-55
56+
Married
Unmarried
Widow
/widowed
Don’t know/no
response
Defecation in
field/outside
house
Traditional pad
Ordinary
old
latrine
Improved old
latrine
Others
Yes
No source of
lighting
Electricity
Badakhshan
Tajik ethnic groups
Baghlan
Hazara ethnic groups
Logar
Pashtun
groups
Male
(80)
N %
14 17.5
23 28.8
24 30
15 18.8
4
5
73 91.3
4
5
1
1.3
ethnic
Total
636
Female
(61)
N
%
22 36.1
21 34.4
17 27.9
1
1.6
0
0
55 91.7
5
8.3
0
0
Faryab
Uzbek/Turkmen ethnic
groups
Male (99) Female
(101)
N
%
N
%
26 26.3 34 33.7
35 35.4 35 34.7
18 18.2 22 21.8
14 14.1 9
8.9
6
6.1
1
1
78 78.8 88 81.1
21 21.2 11 10.9
0
0
2
2
Male
(81)
N %
19 23.5
21 25.9
25 30.9
16 19.8
0
0
70 86.4
11 13.6
0
0
Female
(79)
N
%
42 53.8
16 20.5
16 20.5
4
5.1
0
0
59 75.6
15 19.2
4
5.1
Male
(59)
N %
22 37.3
9
15.3
20 33.9
8
13.6
0
0
43 72.9
16 27.1
0
0
Female
(76)
N
%
25 32.5
35 45.5
15 19.5
2
2.6
0
0
69 89.6
1
1.3
7
9.1
Male
(319)
N
81
88
87
53
10
264
52
1
%
25
28
27
17
3
83
16
0
Female
(317)
N
%
123 39
107 34
70
22
16
5
1
0
271 85
32
10
13
4
0
0
0
0
0
0
0
0
0
0
0
0
0
0
2
2.5
0
0
2
1
3
7.5
1
2.6
17
28.8
23
37.7
1
1
4
4
0
0
2
2.6
21
7
30
9
33
3
82.5
7.5
36
0
94.7
0
41
0
69.5
0
38
0
62.3
0
91
6
91.9
6.1
97
0
96
0
80
0
100
0
74
1
96.1
1.3
245
9
77
3
245
1
77
0
1
2.5
0
0
0
0
0
0
0
0
0
0
0
0
0
0
1
0
0
0
0
68
0
84
1
67
2.6
85.9
1
33
1
61.1
1
30
0.7
49.2
0
97
1
98
1
98
0
97
0
76
0
95
0
73
0
94.7
1
274
0
86
3
268
1
85
2
1.3
1
0.8
0
0
0
0
3
0
56
35.4
38
31.7
193
96.5
44
28
331
52
29
Gender Related Barriers to Access and Utilization Reproductive Health, Mental Care
Source of water
Generator
Gas lamp
Kerosene or oil
lamp
Other
Piped
into
residence
Public tape
Hand pump in
to residence
Public
hand
pump
Covered well in
residence
Covered
will
else where
Open well in
residence
Open well else
where
Spring
River/stream
Pound/lake
Tanker/truck
Others
6
6
65
3.8
3.8
41.1
2
10
61
1.7
8.3
50.8
0
0
7
0
0
3.5
23
40
35
14.6
25.5
22.3
31
56
168
5
9
26
23
10
14.6
6.3
8
2
6.7
1.7
0
2
0
1
15
0
9.6
0
46
14
7
2
7
1
4.4
0.6
2
14
1.7
11.7
1
49
0.5
24.7
23
21
14.6
13.4
33
85
5
13
12
7.5
35
29.2
5
2.5
43
27.4
95
15
25
15.7
12
10
30
15.2
38
24.2
105
17
11
6.9
4
3.3
5
2.5
6
3.8
26
4
2
1.3
18
15
40
20.2
6
3.8
66
10
4
2.5
17
14.2
16
8.1
3
1.9
40
6
29
53
4
1
0
18.2
33.3
2.5
0.6
0
3
11
1
0
0
2.5
9.2
0.8
0
0
0
10
38
2
0
0
5.1
19.2
1
0
5
7
0
0
5
3.2
4.5
0
0
3.2
37
81
43
3
5
6
13
7
0
1
15.2 Gender role in decision making related to health problems
On inquiring about the response to diarrhea and their health seeking behaviors the study shows that overall 72% of male participants and 60% of
female participants were of the view to immediately respond in case they get diarrhea, 28% of male participants and 36% of female participants
are responding at their convenience and 3% of female do nothing if they have a diarrheal cases at home.
The results of the study show that 69% of male participants seek care right away following having cough and 22% of female participants seek
care right away following onset of cough. 3% of male participants and 5 % of female participants take no action on the onset of cough.
30
Gender Related Barriers to Access and Utilization Reproductive Health, Mental Care
The results of this study indicate that 86% of male participants and 78% of female participants are seek care or take the patient to seek care right
away on the onset of vaginal bleeding, 6% of male participants and 12% of female participants believe that in case of vaginal bleeding care
should be sought at convenience and 2% of female participants take no action in case there is vaginal bleeding.
The results of the study indicate that 67% of male participants and 43% are willing to seek c are right away while a child in not moving (child is
unconscious or unable to move), 16% of male participants and 39% of female participants believed that a child who is not moving should seek
care at their convenience and 6% of male participants and 10% of female participants are not seeking care at all while child in not moving. For
the detail information on gender role in decision making related to health problems among different ethnic groups differentiated by male and
female, please refer to the table 2 below:
Table 2
Badakhshan
Tajick ethnic Groups
Male
(81)
N %
57 70.4
24 29.6
Female
(79)
N %
47 60.3
31 39.7
Baghlan
Hazara
Groups)
Male
(59)
N %
38 64.4
21 35.6
No action
Don’t
know/no
response
Right away
When convenient
No action
Don’t
know/no
response
Right away
When convenient
No action
Don’t
know/no
response
0
0
0
0
0
0
0
0
0
0
0
0
1
0
1.7
0
1
0
1
1
8
1
7.9
2
0
2
0
0
0
0
0
0
1
2
0
1
9
1
3
0
64
14
2
1
79
17.3
2.5
1.2
23
51
2
3
29.1
64.6
2.5
3.8
34
24
1
0
57.6
40.7
1.7
0
22
36
3
0
36.7
60
5
0
64
27
6
2
64.6
27.3
6.1
2
16
72
11
2
15.8
71.3
10.9
2
57
20
2
1
71.3
25
2.5
1.3
8
66
0
2
10.5
86.8
0
2.6
219
85
11
4
69
27
3
1
69
225
16
7
22
71
5
2
73
7
0
1
90.1
8.6
0
1.2
64
6
0
9
81
7.5
0
11.4
54
1
1
2
93.1
1.7
1.7
3.4
51
7
2
1
85
11.7
3.3
1.7
86
5
0
1
93.5
5.4
0
1.1
71
9
5
6
78
9.9
5.5
6.6
61
5
0
14
76.3
6.3
0
17.5
61
15
0
0
80.3
19.7
0
0
274
18
1
18
86
6
0
6
247
37
7
16
78
12
2
5
Right away
58
71.6
39
49.4
43
74.1
31
52.5
62
68.9
22
24.2
50
62.5
43
56.6
213
67
135
43
Variable
Name
Response
Diarrhea
Description
to
Cough lasting
more than 2
weeks
Vaginal
Bleeding
Child
not
Right away
When convenient
Female
(61)
N %
25 41.7
34 57.4
Farzyab
Uzbek/Turkmen
ethnic groups
Male
Female
(99)
(101)
N %
N %
80 80.8 66 65.3
17 17.2 25 24.8
Logar
Pashtun
groups
Male
(80)
N %
54 67.5
26 32.5
Female
(76)
N %
51 67.1
25 32.9
Male
(319)
N
%
229 72
88
28
Female
(317)
N
%
189 60
115 36
ethnic
ethnic
Total
31
Gender Related Barriers to Access and Utilization Reproductive Health, Mental Care
moving
When convenient
No action
Don’t
know/no
response
15
0
8
18.5
0
9.9
26
5
9
32.9
6.3
11.4
9
2
4
15.5
3.4
6.9
16
13
0
27.1
22
0
10
15
3
11.1
16.1
3.3
52
14
3
57.1
15.4
3.3
16
1
13
20
1.3
16.9
31
0
2
40.8
0
2.6
50
18
28
16
6
9
125
32
14
39
10
4
15.3 Gender power and role in decision making
The results on the role and power of men and women related to decision making indicate that 66% of women are able to go to shops nearby
their homes provided that they should have companion and 68% of women need approval in this regards.
94% of women are able to visit their relatives and friends in their villages while be accompanied by another person, and 93% of women need
approval to visit relatives and friends in their villages.
96% of women should be accompanied by another person while aiming to visit relatives and friends out of their villages and 94% of them need
approval in this regard.
The results show that 91% of women should be accompanied by another person while attending a marriage party and 89% of them need prior
approval. The study results shows the low decision making power among women as compare to men. For detail information on gender related
role and power of decision making among different ethnic groups please refer to table below.
Table 3. Statistics on gender role and power in decision making
Variable
Name
Go to
nearby
home
Description
shop
your
Visit relatives
or friends in
Accompanied
by person
Need approval
Accompanied
by person
Badakhshan
Tajicks ethnic group
Baghlan
Hazaras ethnic group
Male (81)
Male (59)
N
40
43
45
%
49.
4
53.
8
55.
6
Female
(79)
N
%
61
78.
2
64
86.
5
75
96.
2
N
34
30
38
%
58.
6
51.
7
65.
5
Female
(61)
N
%
60
98.
4
60
98.
4
61
10
0
Faryab
Uzbeck/Turkmen
ethnic groups
Male (99) Female
(101)
N
%
N
%
22
22. 61
62.9
2
50
50. 66
71
5
26
26. 89
88.1
3
Logar
Pashtoon ethnic group
Total
Male (80)
Female (76)
Male (319)
N
16
%
20
N
27
%
35.5
N
112
%
35
Female
(317)
N
%
209 66
18
22.8
27
36.5
141
44
217
68
16
20
73
96.1
125
39
298
94
32
Gender Related Barriers to Access and Utilization Reproductive Health, Mental Care
your village
Need approval
43
Visit relatives
or
friends
outside your
village
Attend
marriage
party
Accompanied
by person
Need approval
53
Accompanied
by person
Need approval
55
57
60
54.
4
66.
3
74
74
67.
9
75
65
75
73
60
98.
7
94.
9
96.
1
82.
3
81.
1
37
47
40
53
42
63.
8
81
61
70.
2
91.
4
72.
4
61
61
61
61
10
0
10
0
10
0
10
0
10
0
53
53.
5
48.
5
77.
8
55.
6
80.
8
48
77
55
80
87
87.9
16
20
73
96.1
149
47
295
93
94
93.1
14
17.5
73
96.1
162
51
303
96
90
90.9
16
20
73
96.1
190
60
297
94
92
91.1
50
18.8
71
93.4
213
67
289
91
90
91.8
19
23.8
71
93.4
201
63
282
89
Gender role and power on various health seeking and health related issues
The results of this study show that the only 46% of women are making decision to seek care in acute emergencies while decision maker is not at
home.
Only 43% of women can make decision by themselves to go to clinics in case they are sick. Only 31% of women are able to make decision to
attend the health facilities while other members of the families are sick. The results show that only 37% of women can make decision to seek
care in case they are encountering emergencies. In 33% of cases women are decision maker in case a member of family is encountering an
emergency.
The results indicate that 85% of women believe that a woman must be accompanied by while visiting a health facility. The results show that in
82% of cases both women and men feel comfortable to seek care for common diseases.
Results indicate the 78% of women and 82% of male are comfortable to seek care from health workers (female for reproductive health
problems, pregnancy and abortions).
24% of both men and women believe that they should offer give of pay a health work to seek quality health care services.
Table 4. Statistics on gender role in different decision making issues:
Variable
Badakhshan
Tajick ethnic groups
Baghlan
Hazara Ethnic Groups
Faryab
Uzbeck/Turkmen
ethnic Groups
Logar
Pashtoon
Groups
Total
ethnic
33
Gender Related Barriers to Access and Utilization Reproductive Health, Mental Care
Name
Description
Male
(81)
N %
36 45.6
Female
(79)
N %
37 46.8
Male
(59)
N %
22 40
Female
(61)
N %
35 61.4
Male (99)
In acute emergency
while decision maker is
not at home, who takes
decision for seeking
health care
Go to health clinic in
case of own illness
Go to health clinic in
case of family member
illness
Go to health clinic in
case of
personal
emergency
Go to health clinic in
case of family member
emergency
Must
someone
accompany when visit
health center
Are you comfortable
receiving care from
male/ female health
worker for common
illness
Are you comfortable
receiving care from
male /female health
worker for specific,
confidential
issue
(pregnancy ,abortion
,genital problems)
Do you think people
give gifts or money to
Own
decision
Male (80)
%
77.1
Female
(101)
N
%
48 48.5
%
22.5
Female
(76)
N %
26 36.2
Male
(319)
N
%
150 47
Female
(317)
N
%
146 46
N
74
N
18
Own
decision
Own
decision
78
97.5
11
13.9
48
82.8
38
63.3
79
79.8
54
54
63
78.8
32
42.1
268
84
135
43
64
80
11
14.3
40
69
36
61
77
77.8
39
39
62
77.5
13
17.1
243
76
99
31
Own
decision
73
91.3
11
13.9
39
67.2
36
60
77
77.8
58
58
63
78.6
12
15.8
252
79
117
37
Own
decision
70
88.6
9
11.4
45
77.6
35
58.3
74
74.7
52
52
62
77.5
10
13.2
251
79
106
33
Yes
44
55
75
94.9
29
50
36
60
37
38.1
84
84.8
50
63.3
73
96.1
160
50
268
85
Yes
53
68.8
44
60.3
55
93.2
55
91.7
80
84.2
91
91.9
72
92.3
69
90.8
260
82
259
82
Yes
61
76.3
36
48.6
55
93.2
54
90
80
83.3
85
85.9
61
76.3
72
94.7
257
81
247
78
Yes
9
11.3
43
59.7
7
12.1
10
16.4
35
36.8
16
16.3
24
30
7
9.2
75
24
76
24
34
Gender Related Barriers to Access and Utilization Reproductive Health, Mental Care
health worker to get
better care
Health Care Provider:
The provider data was collected from health providers working in the Basic Health Centers (BHCs). The target health providers were Community
health supervisors, Doctors, Vaccinators, Midwives, nurses and lab technician. The structured questionnaires were applied. The total of 81
health providers was interviewed.
Socio demographic characteristics of health provider are presented in below table. Around three quarters of the health providers were less than
forty years old. 78% of the health providers were married. More than half of the health providers were living in the health facility catchment
area. About 80% of the health providers were working in the same profession for more than a year.
Thirty nine percent of the health providers said they have received training on the topic that male and female in different ages has different
problems. More than one quarter of health workers received training on the health problems of women and girls, and 19.5% of the health
providers were trained on specific health problems of men and boys. 43.2% of health providers were trained on family planning, majority of
them was midwives, CHS and nurses. 33.3% of midwives, 28.6% of doctors were trained on gender and health issues.
Table 5. Socio demographic characteristics of Health providers:
Variable
Name
Description
CHS (10)
Doctor (12)
Vaccinator
(24)
Midwife (13)
Others (Nurse,
pharmacist , Lab
tech) (22)
Total (81)
N
N
N
N
N
N
%
%
%
%
%
%
35
Gender Related Barriers to Access and Utilization Reproductive Health, Mental Care
Age
Marital status
18-20
0
0
1
9.1
1
4
1
7.7
1
5.3
4
4.9
21-30
5
35.7
4
36.4
8
32
8
61.5
13
68.4
38
46.3
31-40
3
21.4
3
27.3
7
28
3
21.1
5
26.3
21
25.6
41-50
6
42.9
2
18.2
9
36
1
7.7
0
0
18
22
51-60
0
0
1
9.1
0
0
0
0
0
0
1
1.2
Married
11
78.6
9
81.8
22
88
9
69.2
13
68.4
64
78
Unmarried
3
21.4
2
18.2
3
12
3
23.1
6
31.6
17
20.7
0
0
0
0
0
0
1
7.7
0
0
1
1.2
Widow/
male
widower
Living in health facility catchment area
Yes
8
57.1
6
54.5
14
56
7
58.3
7
36.8
42
51.9
How long you are working in this profession
Less than one year
1
7.1
3
27.3
3
12
4
30.8
6
31.6
17
20.7
One to two years
7
50
3
27.3
2
8
4
3.8
6
31.6
22
26.8
Three to five
4
28.6
0
0
10
40
3
23.1
3
15.8
20
24.4
Six to ten
2
14.3
2
18.2
7
28
1
7.7
1
5.3
13
15.9
More than ten years
0
0
3
27.3
3
12
1
7.7
3
15.8
10
12.2
Less than one year
1
7.1
3
27.3
3
12
4
30.8
6
31.6
17
20.7
How long you are working in the current position
36
Gender Related Barriers to Access and Utilization Reproductive Health, Mental Care
When you completed your professional education
One to two years
2
14.3
3
27.3
3
12
5
38.5
4
21.1
16
19.5
Three to five
10
71.4
3
27.3
9
36
3
21.1
7
36.8
32
39
Six to ten
1
7.1
0
0
6
24
0
0
1
5.3
8
9.8
More than ten years
0
0
3
27.3
4
16
1
7.7
1
5.3
9
11
More than ten years
2
15.4
3
27.3
6
25
1
7.7
1
5.6
13
16.5
Six to ten years
1
7.7
2
18.2
5
20.8
1
7.7
2
11.1
11
13.9
Three to five
4
30.8
1
9.1
5
20.8
6
46.2
4
22.2
20
25.3
Zero to two years
1
7.7
1
9.1
4
16.7
0
0
2
11.1
8
10.1
Don’t
response
5
38.5
4
36.4
4
16.7
5
38.5
9
50
27
34.2
know/no
Have you received trainings on the topic that male and
female in different ages has different problems
yes
8
57.1
4
36.4
9
36
6
46.2
5
26.3
32
39
Have you received training that focused specifically on
the health problems of women and girl’s problems
yes
7
50
3
27.3
4
16.7
7
53.8
2
10.5
23
28.4
Have you received training that focused specifically on
the health problems of men and boy’s problems
Yes
4
30.8
4
36.4
30
12.5
1
9.1
3
16.7
15
19.5
ARI
0
0
0
0
0
0
1
16.7
2
25
3
8.1
Diarrhea
5
62.5
3
42.9
1
12.5
3
50
2
25
14
37.8
IMCI
1
12.5
0
0
1
12.5
0
0
1
12.5
3
8.1
Type of refresher training received
37
Gender Related Barriers to Access and Utilization Reproductive Health, Mental Care
Malaria
3
35.5
3
42.9
1
12.5
2
33.3
2
25
11
32.4
Family planning
5
62.5
2
28.6
1
12.5
4
66.7
4
50
16
43.2
HMIS
4
50
1
14.3
2
25
1
16.7
2
25
Gender and health
1
12.5
2
28.6
2
25
2
33.3
1
12.5
8
21.6
Computer skills
1
12.5
1
14.3
3
37.5
0
0
1
12.5
6
16.2
27
Management and Service related variables of health provider’s data:
Most of the health providers said that more number of patients is the reason for increasing patient stay in the clinic. About 73% of doctors
responded that they have some control on staff placement in the health facility. Majority of the health providers (86.3%) responded that people
seek their help outside health facility.
About 63% of health providers treating the patient if they seek help outside the health facility. Majority of health providers (86.4%) provide
health care at patients’ home. Only 38% of health providers said that they can handle emergency issues, the midwives said 76.9%, 50% of
doctors, and 40.9% of nurses responded they can handle emergency issues. About 70% of health providers said they are comfortable dealing
with confidential issues. About 99% of health providers said that men and women have different health issues. 92.5% of health providers
responded that the health facility can address the different health need of male and females.
Table 6.
Variable
CHS (10)
Name
Description
N
%
Doctor (12)
Vaccinator
(24)
Midwife (13)
Others (Nurse,
pharmacist , Lab
tech) (22)
Total (81)
N
N
N
N
N
%
%
%
%
38
%
Gender Related Barriers to Access and Utilization Reproductive Health, Mental Care
What determines length
patient’s consultation time
of
Placement of staff in facility
Vocation days of staff
Do people seek your help out
side of operating hours
Number of patient waiting
8
61.5
8
72.7
12
48
6
46.2
11
57.9
45
55.6
Severity of condition
5
38.5
10
90.9
7
28
9
69.2
7
36.8
38
46.9
Time of day
2
15.4
0
0
2
8
2
15.4
5
26.3
11
13.6
Personal mood
4
30.8
1
9.1
5
20
1
7.7
5
26.3
16
19.8
Daily schedule planned
0
0
1
9.1
9
36
5
38.5
2
10.5
17
21
Others
1
7.7
1
9.1
3
12
1
7.7
2
2.5
8
9.9
Don’t know/no response
0
0
0
0
2
8
0
0
0
0
2
2.5
Limited control
1
7.7
3
27.3
0
0
3
23.1
2
10.5
9
11.1
No control
9
69.2
3
27.3
23
92
6
46.2
12
63.2
53
65.4
Complete control
2
15.4
3
27.3
0
0
2
15.4
3
15.8
10
12.3
Shared control
1
7.7
2
18.2
0
0
2
15.4
1
5.3
6
7.4
Don’t know/no response
0
0
0
0
2
8
0
0
1
5.3
3
3.7
Limited control
1
7.7
6
54.5
0
0
4
3.8
3
15.8
14
17.3
No control
10
76.9
0
0
22
88
4
3.8
11
57.9
47
58
Complete control
1
7.7
4
36.4
1
4
0
0
4
27.1
10
12.3
Shared control
0
0
1
9.1
0
0
4
30.8
0
0
5
6.2
Don’t know/no response
1
7.7
0
0
2
8
1
7.7
1
5.3
5
6.2
Yes
10
76.9
11
100
21
84
10
83.3
17
89.5
69
86.3
39
Gender Related Barriers to Access and Utilization Reproductive Health, Mental Care
Differ to another time
0
0
0
0
2
10
0
0
1
5.3
3
4.2
Treat the patient
4
36.4
10
90.9
9
45
10
90.9
12
63.2
45
62.6
Refer the patient to another care provider
4
36.4
0
0
7
35
0
0
3
15.8
14
19.4
Refused to treat
1
9.1
0
0
0
0
0
0
1
5.3
2
2.8
Others
1
9.1
1
9.1
2
10
1
9.1
1
5.3
6
8.3
Don’t know /no response
1
9.1
0
0
0
0
0
0
1
5.3
2
2.8
Do you provide community
services outside of the health
care facility?
Yes
13
100
10
90.9
23
92
10
76.9
15
78.9
71
87.7
Provision of home care to
patients
Yes
11
84.6
10
90.9
22
88
10
76.9
17
89.5
70
86.4
Sufficient resource support for
your work
Yes
5
55.6
9
81.8
19
79.2
11
84.6
17
81
61
78.2
Salary received on time
yes
6
66.7
7
58.3
17
70.8
11
84.6
18
81.8
59
73.8
Do you feel capable of handling
emergency issues
yes
1
11.1
6
50
4
17.4
10
76.9
9
40.9
30
38
Do you feel comfortable
handling confidential issues with
patients
Yes
4
44.4
12
100
14
60.9
11
84.6
14
63.6
55
69.6
Do female patient usually
comply
with
treatment
prescribed by you
yes
8
88.9
11
91.7
24
100
13
100
20
90.9
76
95
Do male patient usually comply
with treatment prescribed by
you
Yes
9
100
11
91.7
23
100
9
69.2
21
95.5
73
92.4
What is your usual response to
people seeking your help outside
of facility operating hours?
40
Gender Related Barriers to Access and Utilization Reproductive Health, Mental Care
Does the healthcare facility have
the capacity to address the
health needs of different age
groups that is young elderly
Yes
4
44.4
10
90.9
20
83.3
12
92.3
17
85
63
81.8
Do men and women have
different health needs
Yes
8
88.9
12
100
23
100
13
100
22
100
78
98.7
Does the health care facility have
the capacity to address the
different health need of male
and female
Yes
6
66.7
12
100
23
95.8
12
92.3
21
95.5
74
92.5
Are operating hours of health
facility convenient to female
patients
Yes
6
66.7
12
100
23
95.8
12
92.3
21
95.5
74
92.5
Are operating hours of health
facility convenient to male
patients
Yes
7
77.8
10
83.3
23
95.8
12
92.3
21
95.5
73
91.3
Do patient have to wait long to
see the health care provider
Yes
8
88.9
7
58.3
15
62.5
7
53.8
14
63.6
51
63.8
Capability of health providers in dealing different health problems:
The majority of health providers were not capable to treat abortion, only 18.8% said that they can treat abortions and majority of the health
providers were midwives (76.9%). Only one quarter of the health providers said that they can treat physical violence, and the same percentage
said that they can counsel the physical violence victims. Only 2.6% of health providers said that they can treat the rape cases, and 25.6% said
that they can counsel rape cases. 11.5% of health providers said that they can treat attempted suicide cases. About 20% of health providers said
that they can treat depression, and 31.6% of health providers can counsel depression cases. For further detail refer to below table
Table 7. Capability of health providers in dealing different health problems:
41
Gender Related Barriers to Access and Utilization Reproductive Health, Mental Care
Variable
CHS (10)
Doctor (12)
Vaccinator (24)
Midwife (13)
Others
(Nurse,
pharmacist , Lab
tech) (22)
Total (81)
Name
Description
N
%
N
%
N
%
N
%
N
%
N
%
Abortion
Treat
0
0
4
33.3
0
0
10
76.9
1
4.5
15
18.8
Treat
2
22.2
9
75
3
12.5
3
23.1
2
9.5
19
24.1
Counsel but not treat medically
2
22.2
0
0
7
29.2
2
15.4
8
38.1
19
24.1
Can treat
0
0
2
16.7
0
0
0
0
0
0
2
2.6
Counsel but not treat medically
2
22.2
6
50
3
12.5
1
7.7
8
40
20
25.6
Treat
1
11.1
5
41.7
0
0
2
15.4
1
5
9
11.5
Counsel but not treat medically
4
44.4
6
50
13
54.2
5
38.5
8
40
36
46.2
Treat
2
22.2
10
83.3
1
4.2
1
7.7
2
9.5
16
20.3
Counsel but not treat medically
3
33.3
1
8.3
6
25
5
38.5
10
47.6
25
31.6
Treat
2
22.2
8
66.7
0
0
5
38.5
1
5
16
20.5
Counsel but not treat medically
4
44.4
4
33.3
11
45.8
6
46.2
8
40
33
42.3
Physical
Violence
Rape
Attempted
suicide
Depression
Child
neglect
Are the following support consultation mechanisms are available to you in your work
Colleagues
Yes
9
100
11
91.7
23
95.8
13
100
18
85.7
74
93.7
Medical
officers
Yes
8
88.9
9
75
23
95.8
13
100
21
95.5
74
92.5
42
Gender Related Barriers to Access and Utilization Reproductive Health, Mental Care
16 Conclusions






Health is perceived rather as physical, mental well being .Findings of this study concluded that
women have emphasized on mental well being aspect of health and men have emphasized on
physical and economical well being aspect of health.
We found significantly lower decision making power among women of different ethnicity groups
in availing health care as compare to males.
Majority of females were comfortable in receiving health care from male health providers.
The study concluded that most of the participants were of the view that mental disorders are
curable diseases; however these diseases hold negative effects on overall living status of
patients. People are avoiding them, not tending to blend with them in the social gathering and
activities, not greeting and hugging them and not sharing their eating and drinking utensils with
them, nobody is willing to marry their daughters or sons to mentally ill person(s).
The findings of this research concluded that there is insufficient capacity to treatment mental
health disorders in public health facilities, (lack of trained health workers in mental health
disorders and psychologist and mental health specialists at public health facilities even at
hospitals), therefore this phenomenon tend to discourage clients to seek mental health care
from public health facilities and make them to approach Kabul Hospitals and neighboring
countries to seek care.
The study concluded that majority of people especially women are using public health facilities
to seek health care; some of them are seeking care from private health facilities, traditional
healers, mullahs and ziarats as well. Men prefer self medication and medicine over the counters.
The results show that among Uzbek/Turkmen ethnic groups, part of them are seeking care from
neighboring countries.

Majority of women of Hazara ethnic groups seek care from public health facilities, provincial and
Kabul hospitals; some of them are seeking care from mullah, ziarat, using herbal medicine and
medicines. Tajik’s women are using public health facilities, private doctors, self medication and
herbal medicine. Pashtun women use public health facilities and provincial hospital mostly, they
are also taking their patients to mullahs, ziarats and traditional healers.

This study concluded that majority of Hazara are preferring self-medication and medicines over
the counters, some of them are seeking care from the public health facilities. Tajik’s men are
using herbal medicine, seeking care from mullahs and ziarats, in case they are not getting well
they are seeking care from private doctors .Pashtun men are seeking care from public health
facilities and provincial hospital, private doctors and medicine over the counters.

The results of this study concluded that head of households, husband, father and brothers are
making decisions for patients to seek care. Focus group discussions with men indicated that,
majority of women don’t have power of decision making.” Their husbands, fathers or (any male
43
Gender Related Barriers to Access and Utilization Reproductive Health, Mental Care
member of family) are making decision for them to seek care. Focus Group Discussions (FGD)
results with women show that, in very few cases husband and wife together make decision to
seek care. In situations where, there is no male member of the family at home, only then,
women can make decision to seek care.

Hazara, Tajik, Uzbek/ Turkmens women have mentioned that in majority of cases head of
households are decision maker for patients, it was mentioned that in few cases husband and
wife are making decision for patients in their families, and women can only make decision when
there are no male members of the family at home. Pashtun women mentioned that the male
members of the family are decision makers for patients at their families, women need to be
accompanied by mahram (male companion) while aiming to seek health care from public health
facilities. Only in case of emergencies, they can go to health facilities without receiving
permission form the male members of the family.

The study explored that health worker’s harsh behavior at public health facilities, non
availability of medicine at public health facilities, lack of transportations, suboptimal trust of
clients on health worker’s skill and knowledge, non availability of female staff, non availability of
24 hours of services at the public health facilities, and lack of women’s decision making power
are major barriers to seek health care. Shortage of medical supplies and equipments and drug
stock out in some of the public health facilities are mentioned causes of sub-optimal utilization
for all study groups. Poor economic status of people results in their inability to afford the
burden of transportation cost; this was mentioned as barriers for both men and women,
especially in hard to reach areas
17 Policy Recommendations

In order to raise the ethics among health care providers the Ministry of Public Health should
make necessary arrangement for training the staffs on basic medical and professional ethics in
the light of Islamic teaching. Medical and associated allies should include ethics in their teaching
curricula.

Sub-optimal trust of clients on skills and knowledge of health care providers is a barrier to seek
care from public health facilities. Therefore, training programs should be planned based on
regular need assessment; proper follow up system to assess the impact of trainings conducted
to health care providers in order to bring positive change in level of knowledge and capacity of
health care providers.

Lack of trained health care providers on mental health is one the main barriers for
underutilization of the facilities for mental disorders. In order to address this issue the ministry
should pay attention on the training of staffs on basic management and treatment of the mental
44
Gender Related Barriers to Access and Utilization Reproductive Health, Mental Care
disorders. The deployment of the trained and specialist psychiatrist build up confidence of the
clients for using health facilities.

Regular supply of drugs and equipment to public health facilities should be ensured in order to
prevent frequent stock out of drugs at public health facilities.

The ministry should ensure the deployment of the female staffs at the lowest level of care
especially in the pashtun dominant areas.

The government including Ministry of public health along with other line ministries and their
stakeholders should focus to improve three delays , a) delay in access to quality health care
providers, by strengthening referral system and means of transportation especially at hard to
reach areas; b) delay in availability of quality health care services , by deploying more female
staff at public health facilities (train more community midwives and female nurses) , make
arrangement for regular supply of drugs and equipments and c) delay in decision making by
focusing on public awareness through Islamic teaching, role of women in decision making, status
women in Islam. The communities especially women may be empowered to decide about the
fate of their illness of course in the light of the Islamic teaching.
45

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