Afghanistan is at a crossroads again—preventing a descent into chaos

Afghanistan once again appears in the throes of a cataclysmic change. The sight of people gathering in throngs at Kabul airport and desperately clinging to military aircrafts—reminiscent of the ignominious end of the Vietnam War nearly half century ago—are jarring to say the least. With an uneasy calm over much of the country, there is vast speculation as to the future of the country. 

Afghanistan is sadly a victim of its geo-strategic location, with internecine conflicts spanning centuries. Not only did multiple marauding armies try to make their way into the Indian subcontinent through the Khyber Pass, the country was also the platform for “the great game” between global powers. [1] In these “forever wars,” now spanning four decades following the Soviet invasion in 1979, the real victims have been the people of Afghanistan, with generations growing up as “children of war.” [2]

One of the poorest countries of the world, Afghanistan is largely dependent on donor aid for survival. External assistance accounted for almost 76% of GDP between 2005 and 2011. [3] Much has been made of the $2.3 trillion spent by the United States and Allies in Afghanistan since 2001. [4] However, the bulk (>99%) of these funds were spent on military operations, defence procurements, and interest fees. Overall health spending averaged $20-50 per capita annually over this period, and much of it was out of pocket. [5] Sachs estimates that less than 2% of the US spending in Afghanistan ever reached the Afghan people, with a significant chunk likely siphoned off. [6]

Despite challenges, major progress was still made. From having some of the highest maternal and child mortality rates in the world, Afghanistan’s health progress over the last two decades has been impressive. [7] Sadly, gains in recent years have slowed due to conflict, insecurity, and covid-19. [8,9] Significant disparities exist between regions with some conflict affected provinces stuck with low health service coverage rates, for example in some areas, less than 10% of births are attended by a skilled birth attendant or children fully vaccinated. [10] Afghanistan must quickly move into its healing and reconciliation process, and focus on these disparities to ensure that health gains are not lost.

We call upon all the political leadership of Afghanistan, the Taliban as well as other factions, to join hands at this critical juncture to rebuild the country and accelerate the pace of development. The public declaration of amnesty for all Afghan nationals by the Taliban is a welcome first step and must be respected and followed by a concerted effort to establish a compact with the people of Afghanistan, in the true spirit of an Islamic welfare state in the 21st century. 

And there are ample opportunities to shape the agenda and do better. The international community’s support and incentives to maintain the gains in education (especially for girls) and female empowerment and their participation in mainstream social and economic activities will be key to Afghanistan’s development. Expanding current primary healthcare packages to include emerging priorities such as mental health, disability, and other non-communicable diseases is essential. Adolescent health, for boys and girls, should be a priority to ensure a healthier next generation of adults. Covid-19 is still a serious public health issue in Afghanistan and recent events in the country should not detract efforts to prevent and manage the disease. The region is also one of the most vulnerable to climate change which can have enormous consequences on its agriculture, livelihood, and environmental conditions, as well as population displacement. Decades of neglect have also left a multitude of issues related to social determinants of health which must be addressed with alacrity. These all need peace and reconciliation as a fundamental prerequisite. Peace in Afghanistan could also have a hugely positive impact on all neighbouring states and the entire region. The people of Afghanistan must be left to discuss and formulate a process for rapprochement and reconstruction.

The Taliban government has a unique opportunity at this time to consolidate and accelerate Afghanistan’s progress, and in its words “serve the people.” Women and children’s health, education, and rights, as well as women’s employment opportunities, will be central to progress in health. Global support and developmental assistance must follow to help Afghanistan attain its sustainable development goals. 

Zulfiqar A Bhutta, director, Institute for Global Health and Development, The Aga Khan University, South-Central Asia, East Africa & United Kingdom.

Nadia Akseer, Bloomberg School of Public Health, The Johns Hopkins University, Baltimore, USA.

Suraya Dalil, director, Special Programme on Primary Health Care, WHO Geneva.

A. F. Akbari, Independent Health & Development Expert, Ottawa, Canada.

Ataullah Saeedzai, Ministry of Public Health, Government of Afghanistan, Kabul, Afghanistan.

Competing interests: The authors declare no conflicts of interest. Suraya Dalil is a former minister of health of Afghanistan. 


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