Afghanistan faces multiple crises rooted in failure to build a robust health system

The health system in Afghanistan continues to struggle with a lack of funds and structure while pressures increase. Governmental policies and climate change and adding to the burden

February 07, 2024 by Peoples Health Dispatch
File Photo: Direct Relief

The intensity of conflict experienced in Afghanistan over the past decades might have decreased but the health emergency persists, as Wahid Majrooh, former Minister of Public Health, told the World Health Organization (WHO) Executive Board late in January. “Despite my wish to maintain optimism, the historical situation in my country and the evolving geopolitical situation in the region convey a worrying message about the upcoming years.”

Afghanistan is facing multiple health challenges: from the ongoing vaccination campaign against polio and the effects of a prolonged period of drought to the impact of deadly earthquakes in 2023. It is becoming increasingly clear that unfortunately, Afghanistan has been exposed much more than others to both human-induced and environmental catastrophes, Majrooh reflected. Whether national and international structures are ready to recognize that is another matter.

One of the health crises faced by Afghans is in the field of women’s and children’s health. Healthcare services for infants are particularly strained, as existing capacities are nowhere near those needed to respond to children’s needs. Existing departments are trying to provide care for dozens of children more than what they were prepared to care for, while trying to comfort parents who often have to travel long distances in order to reach the hospitals.

The country is also facing alarming levels of maternal and infant malnourishment, which is contributing to the numbers of young children in need of hospital care. According to data from the Integrated Food Security Phase Classification, approximately 4 million pregnant and breastfeeding women, and children under 5 years of age, suffered from acute malnutrition in 2023.

The food shortage is being exacerbated by climate change. For the past three years, Afghanistan has been experiencing a continuous drought, and current levels of snow — standing at only 45-60% of standard precipitation — are indicating that this could continue for even longer.

Women are bearing a disproportionate burden in all of these cases. As hunger continued to spread in Afghanistan over the past couple of years, Doctors Without Borders (MSF) warned: “Some accounts suggest that when there is not enough food for everyone in a household, women and girls may be deprioritized.” Needless to say, this is certain to have long term effects on their health, be it fewer chances of breastfeeding to long-term effects on growth and development.

Women also take the back seat when it comes to seeking healthcare. MSF warned that families might act faster when the ill child is a boy, meaning even grimmer health outcomes for girls.

Read more | Taliban bans women from attending universities in Afghanistan

More (literally) human-induced disasters are to be added on top of this. Restrictions on women’s education, work, and travel imposed by the government have meant fewer health workers present in the health system. Last year, women wrapping up their medical studies were not allowed to write their exit exams. Those who were already employed in the sector and were not deterred by the fact that salaries were paid on an irregular basis even before August 2021, are reporting growing concerns about security when traveling to work — as not all are able to travel with a male companion as the rules require.

This, in turn, has contributed to less presence at work and, probably, a reduction in the availability and quality of health services where women tend to prefer consultations with other women, including, of course, reproductive and maternal services.

Judging from statements published on this topic, reports about the different kinds of attacks against women’s rights in Afghanistan left Western leaders and the country’s main donors simply aghast. After all, before fleeing on August 15, 2021, the US-led military coalition left behind significant contributions to the health system in Afghanistan, especially for women — at least from their point of view.

Such an assessment is a serious overestimation of the situation left behind in other areas of health services by the US and its allies. Be it in the Taliban or US-contractors’ era, over the past decades, there were only shy attempts to build anything resembling a real health system — something that is as important for women’s health as access to education or equal participation in health workplaces.

Taking for granted that the change of governance in 2021 is the sole culprit for faltering health indicators would be wrong, at least judging from more recent field reports. Following an international solidarity visit conducted in December 2023, activists from the Indonesian organization MER-C told People’s Health Dispatch: “Afghanistan is not like what we thought and what we often heard in the news.”

While the activists observed a notable presence of both communicable diseases and malnutrition among children in Herat, one of the regions affected by the October 2023 earthquake, they also saw ongoing efforts to rebuild infrastructure, including bridges and highways, with the support of the Chinese government.

Read more| 2,400 dead in massive earthquake in western Afghanistan

Not less important, MER-C noted the interest of communities and local administration in Herat in strengthening the local health system in a way unlike after the 2001 war, building upon the experience of MER-C’s endeavor to build the Indonesian Hospital in Gaza. This would entail building services based on locally assessed needs, and incorporating them within a wider, more homogeneous system.

The system currently in place is different: a decentralized system relying on contracting aid and community organizations for the provision of health services in different provinces. The money to fund it has always come from foreign donors, including the World Bank and similar institutions, meaning that cost-efficiency, rather than health system strength, was (and remains) the guiding thought.

International financial organizations, including the World Bank, might see the current health system as a good path towards Universal Health Coverage (UHC), but organizations supporting healthcare delivery in the field remain concerned about its sustainability.

Taking over the contracting of health service providers from the Ministry of Public Health, UNICEF referred to the existing system as a model “resilient to conflict and a change in de facto governance.” Not much later, MSF described the same system as one where aid organizations have become substitutes for a real public health sector, “a role that cannot be sustainably filled by international actors and particularly when it involves decisions affecting policies and improvements of Afghanistan’s health system.”

The absence of a true public health system is particularly felt at times of crisis, just like the one that Afghanistan has been living through for years. As the economic aspects of this crisis sharpened, people’s capacities to shoulder additional expenses — which are unavoidable under the chosen model — decreased. In MSF’s experience, more than 97% of people in 2022 experienced financial challenges because of healthcare expenses, including travel to health facilities and buying medicines. Financial protection, usually a flagship element of UHC, seems to be abandoned in the case of Afghanistan.

People’s Health Dispatch is a fortnightly bulletin published by the People’s Health Movement and Peoples Dispatch. For more articles and subscription to People’s Health Dispatch, click here.