Amid Afghanistan’s political crisis, a health system at ‘breaking point’

The hectic scenes of men and women racing along the runway of the Hamid Karzai International Airport in Kabul as a U.S. military aircraft takes off, desperate to escape Afghanistan as the Taliban took over the country’s capital, grabbed international attention, and for a moment, took the spotlight away from the coronavirus pandemic.

But COVID-19 remains a challenge in Afghanistan, on top of other medical and humanitarian crises that are adding pressure to an already fragile health system. Weeks of conflict have resulted in an increase in trauma injuries, and demand for emergency medical and surgical services. Field reports in Kabul and other large cities indicate increasing cases of diarrhea, malnutrition, high blood pressure, COVID-19-like symptoms, and reproductive health complications, according to the World Health Organization.

“The health infrastructure in Afghanistan was already fragile, and it was underfunded [and] under-resourced. And so my concern is that the Afghan health system is basically at a breaking point. And that is a major, major concern,” Martine Flokstra, operations manager at Médecins Sans Frontières for Afghanistan, told Devex.

Multiple disasters

Data show a decline in COVID-19 cases in the country, but the violence in recent weeks that led to huge displacements and people moving in close clusters could be another opportunity for heightened COVID-19 transmission in the country.

“What is of concern is that you've had people [moving] from one location to another. You've had people interacting very closely in close quarters … and in those situations, you would have people not following the protocols on COVID prevention,” Necephor Mghendi, head of the Afghan delegation of the International Federation of Red Cross and Red Crescent Societies, told Devex.

“We will know in two weeks, up to three weeks, whether this situation has contributed to the emergence of another wave of COVID-19,” he added.

Since more than a week before the Taliban takeover of the capital, IFRC has also been appealing for greater international support as millions in Afghanistan suffer from a convergence of disasters — more than 80% of the country is experiencing drought, and ongoing hostilities have displaced thousands of people in need of humanitarian assistance.

Meanwhile, after a brief drop in patients amid the hostilities, MSF is now starting to see a steep rise in patients coming to its hospital in Lashkar Gah, the capital of Helmand province in the southern part of the country. Flokstra said around 650 people are now arriving at their emergency room on a daily basis, and they’re considering expanding operations to other areas amid reports of some organizations leaving the country.

Facilities supported by International Committee of the Red Cross have treated close to 50,000 wounded patients since June, and its medical teams and physical rehab centers expect more patients in the coming months and years “as they recover from wounds from explosive devices that litter the country, many of them newly laid in recent weeks,” said Robert Mardini, ICRC’s director-general.

WHO-supported health facilities also received some 13,897 conflict-related trauma cases only this July, a significant leap from 4,057 cases in July 2020.

The situation, however, is very fluid. In a statement released Wednesday, WHO Regional Director for the Eastern Mediterranean Dr. Ahmed Al-Mandhari said WHO and partners have conducted an initial assessment of health needs among displaced populations, but that “interventions have been on hold for the past 36 hours due to insecurity.”

A financial crunch

The massive needs on the ground require funding, but international and local organizations alike are facing difficulties in raising money. ICRC has appealed for 79 million Swiss francs ($86 million), but has so far only raised 30 million Swiss francs. IFRC has also only received 1 million Swiss francs in response to its appeal for 15 million Swiss francs, said Mghendi.

But the situation seems to be more dire for some local health NGOs, many of them contracted by Afghanistan’s civilian government to deliver health care across the country. Now they’re left to continue that work, while some of them have yet to be paid for services rendered in the past few months.

Officials at local NGO Assistance for Health, Education and Development, or AHEAD — who requested anonymity out of fear for their and their colleagues’ safety — said the previous government still owes them about 400 million Afghani ($5.1 million). But they are now at a loss about claiming their payment, which would be vital for them to continue providing basic health services, COVID-19-related activities, and paying their staff members’ salaries. Since July, they’ve been delivering those services without a contract, and have taken out private loans to sustain their operations.

“Who will pay? Would the new government basically abide by the commitments made by the previous government with the change structures? … [We] are operating with a massive debt from private lenders [and] medical suppliers. And we don't know what to do right now, who's our point of contact? The previous government was very [unresponsive] in telling us what [to] do, what will happen, or [taking] any responsibility,” one of the officials said.

They were hoping the World Bank, which serves as administrator for the Afghanistan Reconstruction Trust Fund — and from which the government sources funding to pay NGOs for their delivery of health care services — would provide guidance on how they can be compensated for the costs they’ve incurred, including past dues.

“Our message is — particularly to the World Bank, and maybe other international organizations — to step up, engage with the NGOs directly,” one official said.

Frustrations are running high at the organization as they’re not only dealing with fatigued medical suppliers whom they worry may soon stop providing medicines because of their inability to pay on time, but also with concerns for the safety of their staff, some of whom are in hiding for fear of reprisal after rejecting Taliban demands in prior engagements with the group.

“We've lost contact with some of our colleagues. I'm not sure if they are harmed or anything, but we just cannot reach them,” the AHEAD official added.

A broken system

There have been several improvements in the delivery of health services and health indicators in Afghanistan since the ouster of the Taliban regime in Afghanistan in 2001. A new model was put in place in which NGOs — both international and increasingly national — continue to provide health services, but under the guidance and control of the civilian government. And a key focus included reaching people in remote parts of the country.

According to the Afghanistan Health Survey of 2018, conducted by a third party evaluator, there’s been much progress on antenatal care coverage and the number of births attended by a skilled birth attendant. Progress was particularly seen among rural women, for which antenatal care coverage increased from 4% to 51%, and births carried out by a skilled birth attendant increased from 8% to 61.1% from 2003 to 2018.

But progress is uneven, and these two maternal health indicators have stalled or even slightly reversed for women in the lowest wealth quintiles. Contraceptive uptake also dropped from 14.2% in 2010-2011 to 8.8% in 2018, according to the survey. Meanwhile, all child immunization rates dropped nationally from 2015 to 2018.

“While indicators definitely improved (and faster than some comparable areas in other countries), there are still major needs in most areas, like maternal health, child health, whereby also the nutrition situation remains worrisome,” said Egbert Sondorp, a public health specialist who led the third party monitoring of Afghanistan’s national health services from 2016 to 2019, which included the health survey in 2018.

He also said that health services were heavily reliant on international funding, and that health financing dependent on domestic resources “never materialized.”

NGOs have complained of corruption at the health ministry, and last year four were charged with corruption. Donors, however, are partly to blame for some of the challenges in fixing Afghanistan’s health system.

A report by the Special Inspector General for Afghanistan Reconstruction, who provides United States government oversight on Afghanistan reconstruction, said “U.S. officials sometimes made the problem worse by designing reconstruction programs without regard to the Afghan government’s ability to sustain them.”

The operating costs of a hospital in Paktia province whose construction was funded by USAID, for example, “were 180 to 540 percent those of the one it was meant to replace.” And plans for the construction of that hospital were only shared to the Afghan Ministry of Public Health a year after construction began, according to SIGAR.

Organizations are watching closely, uncertain what the future holds under the Taliban. There are already fears that female health workers will not be allowed to work, and that women will be prevented from pursuing education, including those wishing to become doctors and nurses — hampering efforts in the last two decades to address shortages of female health workers, including midwives.

So far, female health staff are still able to continue their work, at least for MSF and IFRC, including the Afghan Red Crescent Society.

“What will happen now? The new regime may — again, like before — not have a specific interest in the sector and by and large condone or even support the way it currently runs, provided rules are obeyed. As has been the case in the areas that have been under Taliban control for much longer,” Sondorp said.

But funding will be a key issue. And if current donors pull out, he said “much of the system will soon collapse.”

Update, Aug. 19, 2021: This article has been updated with the name of local organization Assistance for Health, Education and Development.