940 Bull World Health Organ 2009;87:940–949 | doi:10.2471/BLT.08.054858 Trends in the quality of health care for children aged less than

Objective To study trends in the quality of the health care provided to children aged less than 5 years in Afghanistan between 2004 and 2006. In particular, to determine the effect on such quality of a basic package of health services (BPHS), including Integrated Management of Childhood Illness (IMCI), introduced in 2003. Methods In each year of the study, 500–600 health facilities providing the BPHS were selected by stratified random sampling in 29 provinces of Afghanistan. We observed consultations for children aged less than 5 years, interviewed their caretakers, interviewed health-care providers and measured adherence to case management standards for assessment and counselling in a random sample. Findings The quality of the assessment and counselling provided to sick children aged less than 5 years improved significantly between 2004 and 2006. A 43.4 % increase in the assessment index and a 28.7 % increase in the counselling index (P < 0.001) were noted. Assessment quality improved significantly every year and was statistically associated with certain characteristics of the provider (being a doctor, having a higher knowledge score, being trained in IMCI, being part of a “contracting-in ” mechanism and providing a longer consultation time) and the child (being younger and having a female caretaker). Counselling quality was also significantly associated with these characteristics, except for provider cadre and child age. The presence of clinical guidelines and the frequency of supervision were significantly associated with improved quality scores in 2006 (P < 0.05 and < 0.01, respectively). Conclusion Quality of care improved over the study period, but performance remained suboptimal in some areas. Continued investments in Afghanistan’s health system capacity are needed