In 2002, the international community came together to assist Afghanistan in addressing its dire health indicators, especially for women and children. At the time, the major causes of death among children were diarrhoea, acute respiratory infection and malaria, and other vaccine-preventable diseases. For women, childbirth was the greatest risk to their health and survival with some of the highest rates of maternal mortality in the world.
The efforts of the international community and Ministry of Public Health in Afghanistan to address these issues in a coordinated manner led to great improvements in health status and life expectancy for the population. A major contributor to this was the development and implementation of a Basic Package of Health Services (BPHS). This addressed the major health issues which were causing the majority of mortality and morbidity at a primary care level. [1] There were seven components to the BPHS: maternal and newborn health, child health and immunisation, nutrition, control of communicable diseases, mental health, disability, and provision of essential drugs. The results were impressive. Equity of access to basic health services was greatly improved; the number of health facilities were increased; a healthcare supply chain and management structure was established; the capacity of the Ministry of Public Health to organise, manage, and steward health services was developed; and the number of midwives and trained health workers, especially female health providers, were increased. [2,3]
Current issues and needs
With the US withdrawal from Afghanistan and the Taliban takeover of the country in the past month, there is now a great risk that the health gains of the past 20 years will be lost. The hurried withdrawal of diplomatic and UN staff by many countries and a mass exodus of trained personnel, has left the health of the population at risk of regression and with decreased access to health services. The critical risk in all of this is that assistance by donors will be stopped. These risks to population health have been further exacerbated by the huge influx of people from unsafe areas into urban areas which is straining all systems, including the health system. There is a risk of drought and food insecurity as food imports have been stopped and borders have been closed. The banking system is collapsing to the point that people do not have access to cash. Unemployment is rising sharply. Economic and social systems are breaking down due to a lack of functioning government structures. The issues faced by the health system are a lack of funding and procurement systems for obtaining essential drugs; a shortage of health workers at facilities due to uncertainty and the loss of many health professionals; and increased chronic and acute malnutrition due to food security issues. These issues will greatly impact on the health system being able to function and will lead to increased health risks, chronic malnutrition, and decreased health services. Without money, within a few months most of the BPHS and hospital facilities might cease to be operational and health professionals will leave.
Afghanistan needs both immediate and long term solutions to avoid health service disruptions and to protect the health status of Afghans, especially the vulnerable, women, infants, and children.
Actions to address the immediate needs
The immediate needs are for opening and maintaining health facilities and providing emergency drug supplies to those areas—especially urban areas—where they are in short supply and are critically needed. Firstly, these require funding. Afghanistan’s healthcare system has received core financial support from the World Bank and Afghanistan Reconstruction Trust Fund (ARTF). This bank-administered trust fund is a basket of funding for BPHS and hospital services. It is funded by 34 donors, with over 80% provided by the European Union, USAID, and the World Bank. [4] The agreements were made with the previous government so it may be difficult for these agencies to release funds to the Taliban government, or any interim government, which has not been recognized by these donors. Prior to 2002, however, many agencies and donors provided direct funding to national and international NGOs for the provision of health services in various parts of the country. So while the ARTF may not be able to fund health services directly through the unrecognized Taliban government, it may be able to find other creative ways, based on humanitarian grounds, to directly fund NGOs, WHO, and UNICEF, to ensure the health services continue at the BPHS facilities and health workers are paid for coming to work.
Secondly, due to the necessity of retaining all female health workers and protecting their safety, there needs to be dialogue with the Taliban appointed health leaders to guarantee female health workers are able to continue providing health services at the BPHS facilities. Without female health workers there would be an insufficient number of health workers and their absence would create huge barriers for the women in Afghanistan to receive needed and essential health services.
Thirdly, steps must be taken to ensure that routine immunization continues, including those for polio eradication. This requires security and pay for vaccinators and funding for the procurement of vaccines. For Afghanistan to regress in its efforts to eradicate polio at this stage, would threaten the entire polio eradication programme in the region.
Fourth, and importantly, Afghanistan has done reasonably well in controlling covid-19-related excess mortality. It has established diagnostic and therapeutic services in major cities. Any large-scale disruption of supplies, services, and health information related to this could have massive public health consequences.
Actions to address the long-term needs
The long term picture for the country and future government is unclear at this point, but that does not mean there should not be an effort to plan and organize for long term needs. Donors, perhaps led by a UN agency or the World Bank, should take a health systems approach built on the foundations of primary healthcare to ensure a comprehensive and coordinated response, without any disruptions. They should ensure that short term humanitarian assistance can support longer term development goals. For example, humanitarian agencies could work within the existing health system network of facilities built over the last 19 years to protect services and jobs already in place, and to sustain gains achieved over the last two decades. The World Bank and ARTF donors should start discussing healthcare support options for the people of Afghanistan, who are the real victims of conflict for over four decades. In addition to the immediate measures proposed above, these should be based on solid and proven evidence-informed strategies with alternative options for financing in the medium to long term.
We call upon the major ARTF funders, the European Union, USAID and World Bank, other donors and UN agencies, WHO, UNICEF and UNDP, to search for responsive, innovative ways to ensure that Afghans are not abandoned with regard to their health and nutrition needs. Women, children, the poor and vulnerable are most at risk during this extraordinary political transition. The immediate health needs of 38 million Afghans cannot wait for recommendations or delays caused by extended dialogue—they need urgent action now.
Ahmad Shah Salehi, Health Economist, Former Senior Policy Advisor to Health Minister of Afghanistan.
Nadia Akseer, Epidemiologist-Biostatistician at Johns Hopkins Bloomberg School of Public Health.
Zulfiqar A Bhutta, Co-Director and Robert Harding Inaugural Chair in Global Child Health & Policy at Centre for Global Child Health, the Hospital for Sick Children, Toronto, Canada and Founding Director of the Institute for Global Health & Development at the Aga Khan University.
Karl Blanchet, Director of the Geneva Centre of Humanitarian Studies, and Professor in Humanitarian Public Health at the Faculty of Medicine, University of Geneva.
Suraya Dalil, Former Minister of Public Health of Afghanistan, Director of WHO Special Programme on Primary Health Care.
Ferozuddin Feroz, Former Minister of Public Health of Afghanistan.
Wahid Majrooh, Acting Minister of Public Health of Afghanistan.
William Newbrander, International Health Advisor.
Ahmad Jawad Osmani, Former Minister of Public Health of Afghanistan.
Khakrah Rashidi, Senior Advisor, Ministry of Public of Afghanistan.
Competing interests: We declare no competing interests.
References:
- Akseer N, Salehi AS, Hossain SMM, Mashal MT, Rasooly MH, Bhatti Z, Rizvi A, Bhutta ZA. Achieving maternal and child health gains in Afghanistan: A Countdown to 2015 country case study. Lancet Glob Heal. 2016;4(6):e395–e413.
- Newbrander W, Ickx P, Feroz F, Stanekzai H. Afghanistan’s Basic Package of Health Services: Its development and effects on rebuilding the health system. Glob public Heal An Int J Res Policy Pract. 2014;9 (Suppl 1(July):S6–S28.
- Salehi AS, Akseer N. Independent Assessment of the Design and Performance of Primary Health Care in Afghanistan [Internet]. 2020. Available from: https://moph.gov.af/sites/default/files/2020-11/Final report of primary health care assessment_12 November 2020.pdf
- Das JK, Akseer N, Mirzazada S, Feroz Z, Noorzada O, Armstrong CE, Mukhtar K, Naeem AJ, Bhutta AZ. Scaling up primary health services for improving reproductive, maternal, and child health: A multisectoral collaboration in the conflict setting of Afghanistan. BMJ. 2018;363:1–9.