Supporting health care in Afghanistan
With the Taliban in control, increasingly restrictive rules for women and girls, and an exodus of health workers, among other challenges, Afghanistan’s health sector faces a complicated, dire future. But there are ways that the international community can help
How did the long war in Afghanistan harm its health system and its people’s health?
War and conflict unfortunately have been part of Afghanistan’s story for decades. The impacts are multifaceted and complex, affecting both the fabric of the society and its institutions. Conflict deprived the health sector and the people of the capacity and quality of services. It affected the quality of medical education, health infrastructure, and the coverage and quality of health services.
Resources in conflict zones are limited, and often diverted to military sectors. In Afghanistan, conflict affected government oversight on funding and service delivery, leading to low-quality health services, inequity and misuse of resources. It contributed to corruption – a painful problem in our health system and government.
Physical injuries caused by conflict tripled the burden of communicable and non-communicable diseases and exacerbated the already fragile health system. This burden, coupled with poor living conditions, sanitation, access to clean water, quality of life and nutrition, exposed people to epidemics. It had repercussions on the legitimacy of and trust in the health system that depended on its ability to address the health needs of communities, especially when the health system remained the only source of hope, and the only public service available in rural areas.
During the conflict emergency leading to the collapse of the Afghan government, coupled with the Covid-19 pandemic, it was only the ‘white gown heroes’ providing services when other sectors could not. Over two decades of conflict, Afghanistan’s health system was a bridge for peace.
Health facilities and staff were the only representatives of the central government allowed to operate in rural areas, as medical personnel, and as mediators and trustworthy partners. After the upheaval of 15 August 2021, the health system remained the only functional institution.
The situation today is even more complex. But one major challenge, which will have repercussions for generations, is the Taliban’s restrictive policies. The ban on Afghan women’s and girls’ education, coupled with their inability to access healthcare services and participate in decision-making, poses serious threats to the health and well-being of mothers and children. Moreover, eight million Afghans – including trained medical staff – have left the country, leading to a loss of institutional memory.
The mental health burden on women and girls and their families affects the health of the whole society and the economy. The Ministry of Public Health struggles to fulfil its stewardship and leadership role in health system governance. Funding shortfalls, because of the international community’s shift from development aid to humanitarian aid, have resulted in unsustainable commitments and ineffective coordination.
What are your expectations of the international community?
The international community needs to invest in and promote efforts to highlight health as a means for peace, to ensure that it builds trust between the health system and society. Conditional engagement with the ruling authorities is currently the only option to ensure that Afghans, especially mothers and children, have access to basic health services. That requires mutual commitment for accountability and transparency to prevent any further deterioration of existing inequities or misuse of international aid for political agendas.
The international community also needs to engage with the diaspora. Afghans left the country physically but not morally: our hearts are still there. We are still connected to our communities and can play an effective role in policymaking, advocacy, training and even service delivery. The health sector exemplified neutrality and impartiality until August 2021, and Afghan health professionals expect and advocate that the sector continues to be non-political.
There needs to be diplomatic pressure on the ruling authorities in Afghanistan to create an inclusive environment where women and girls are part of decision-making and have access to education and quality health care provided by professional and trained human capital.
Globally, health sectors operate in the context of protracted conflict emergencies where, in addition to several other challenges, the social fabric is affected and trust is questioned. In these situations, the health leaders who are the first responders – a midwife, a nurse, a surgeon – need the skills and capacities beyond what international organisations traditionally focus on. They need to be equipped with leadership and advocacy skills, and an understanding of the geopolitical dynamics of the region they operate in and their impact on an operating theatre in Afghanistan, stocks in Dubai or a vaccine factory in Iran. We require a paradigm shift in global health leadership for a more comprehensive and wholistic approach towards global health rather than the siloes we are stuck in.
What are the key political choices that should be made?
If the Taliban wants international and social support, it must prioritise women’s health and education and realise the value of equity. Those are key for trust building, domestically and internationally.
Sustainable funding also matters. Any existing short-term projects should be aligned with national priorities, and such alignment itself requires institutional capacity and stewardship.
Remittances from Afghans abroad are significant, but they are sent directly to families, who decide whether to invest them in their health or other aspects of family life. Systematic steps need to be taken to institutionalise and channel remittances specifically to health facilities and the health needs of communities.
To fill the human capital gap, at the Afghanistan Center for Health and Peace Studies we have created a network to connect the Afghan diaspora to the international network and the health system in Afghanistan. We believe that Afghan health professionals have a great amount of experience gained over two decades, which could be shared with health systems experts in other fragile settings such as Syria or Yemen and further enriched by the experience gained in these settings. We have created teams of professionals from Afghanistan and their peers in other fragile settings, and established partnerships with international institutions to conduct capacity development, advocacy and awareness programmes for Afghans, especially women and girls and female health personnel. We are leveraging digital platforms and artificial intelligence to share the knowledge of the diaspora community with the Afghan health system.
