Introduction by Croakey: In 2021, the Taliban takeover of Afghanistan following the withdrawal of United States troops led to widespread alarm about the implications for the population’s health, especially for women and girls.
Writing for Croakey in August 2021, public health physician Professor Mike Toole urged the international community and aid organisations to safeguard the human rights of women and girls, and protect the health gains of the past two decades.
Since then, the Taliban’s exclusion of women has been “relentless and systematic”, according to the United Kingdom’s ambassador to the United Nations, Barbara Woodword, who recently said there had been “16 decrees in 16 months seeking to erase women from society”.
She said that 15 percent of NGOs had paused all work in Afghanistan and 68 percent had significantly reduced operations, stating “humanitarian aid can’t happen without women”.
On 13 January, several members of the United Nations Security Council met and urged the Taliban to end its repressive treatment of women, calling for a reversal of bans on women working for aid groups or attending universities and high school, according to an Aljazeera report.
The immense health challenges in Afghanistan, which has suffered more than 40 years of conflict, natural disasters, chronic poverty and food insecurity and is described by the UNHCR as experiencing “one of the world’s worst crises” – will be in the spotlight at the World Congress on Public Health, which will be held in Rome in May.
Dr Wahid Majrooh, a former Minister of Health in Afghanistan, will present on the impact of conflict on health systems, and previews his presentation below.
This article is published as part of the #WorldInTurmoil series, a collaboration between the World Federation of Public Health Associations and Croakey Health Media in the lead up to the World Congress on Public Health.
Wahid Majrooh writes:
Picture the scene at a provincial hospital at Lashkar Gah in Afghanistan’s Helmand Province in May 2009.
In the courtyard of the hospital compound, there is a lot of activity. A construction project is underway by a local company and supervised by the British Department for International Development, guarded by armed men.
Inside the hospital, British army engineers are busy installing an oxygen distribution system, guarded by their heavily armed and uniformed colleagues. Beside the hospital, trucks hired by UNICEF are offloading food for the feeding centre inside the hospital. The trucks are guarded by local Afghan National Police Forces.
All that is missing, in this very active provincial hospital, is patients.
Other than a few destitute elderly, who seem to use the hospital as a shelter, the wards are empty.
The people living around the hospital are afraid. The hospital is built on the riverside, and just across it a small forest which is used by opposition troops to launch rocket and mortar attacks on government and army buildings.
This is just one example of the many ways that conflict can harm health and reduce peoples’ access to healthcare.
Multiple effects
Conflict has direct and indirect effects on societies and overall capacity of service delivery through public and private institutions. Economic activities are disrupted, while increased military spending results in reduced funding for social services, especially the health sector which is overburdened with increased demand due to conflict causalities.
Following the collapse of government in Afghanistan, the preliminary official GDP statistics show that the economy contracted by 20.7 percent in 2021 and the health sector has been close to collapse.
Conflict also results in the destruction of infrastructure such as hospitals and the disruption of essential services and overburdening of health facilities due to excessive causalities due to violence. Conflict deviates resources and causes extensive brain drain. In this process, women and children suffer disproportionately from indirect effects, including displacement, disease, and malnutrition.
As well, conflict generates additional health needs. Some diseases may increase due to overcrowding and unsafe water supplies, while others may be exacerbated through disruption of routine health services, such as immunisation.
Four major infectious causes, including respiratory infections, diarrhea, measles, and malaria where endemic, account for 60–90 percent of deaths among conflict-affected populations, often exacerbated by malnutrition.
Chronic diseases such as coronary heart disease, hypertension, diabetes and respiratory diseases can worsen in emergencies, becoming major health issues among older people. Those with chronic diseases requiring long-term management may be at increased risk due to treatment disruptions.
Mental health is often a major concern. Sexual violence is increase in conflict, affecting predominately women and girls. While health needs often increase, ability to deliver health services is often severely constrained.
Historical context
Back at the time of this scene I described earlier, in 2009 government public services were already limited due to long-term under-investment by conflict.
Thousands of families fled the intense fighting going on between Taliban fighters and government forces in several provinces, overwhelming the capacity of already weakened health system. Emergency stocks at Kabul hospitals were used to address the immediate needs of the IDP camps in Kabul city leaving the hospitals with no or small number of emergency kits.
One of the main reasons why health systems collapse in times of conflict is the difficulty of retaining qualified staff, especially female workers, in insecure areas.
Due to conflict, large number of health facilities in remote areas in Afghanistan suffer from lack of health personal especially women. In 2021, for example, in the whole Paktika province, there was only one female doctor in 2021, and in Zabul Provincial hospital, female doctors’ positions had been vacant for more than a year.
The situation was further exacerbated when qualified human capital left the country following the collapse of government, leaving hundreds of health facilities, particularly in the private sector, without trained and qualified staff.
During the year following the change of the government, 99.5 percent of senior and mid-level managers were kicked out of the system, undermining institutional memory and service delivery capacity.
Health service financing is severely disrupted during conflict, leaving staff with irregular or no salaries for almost six months.
Lack of a safe environment for healthcare personal has made the situation even worse. According to John Hopkins University, 81 percent of female health workers reported safety issues that including being stopped and harassed by the Taliban because they did not have a Mahram.
In 2017, the International Committee of the Red Cross (ICRC) said the Taliban, Afghan forces and other groups had conducted more than 240 attacks on medical facilities in the previous two years, in violation of humanitarian laws.
“These attacks erode an already extremely fragile health system: they have damaged or destroyed clinics and hospitals and killed or injured countless health professionals. Others have been forced to leave their jobs or flee, and many patients have been afraid to seek care,” the ICRC said.
Donor fatigue
In conflict-affected countries, humanitarian programming can be derailed by corruption. It can result in misallocation of resources intended to alleviate suffering and further increases the vulnerability of conflict-affected populations.
According to reports from Afghanistan, the current de-facto authority is abusing the influx of humanitarian aid provided in the face of extreme poverty in the country, prioritising their fighters in aid distribution lists.
In Afghanistan, during the last two years of the former regime and in the face of escalating conflict across the country, there were clear signals of donor fatigue, lack of interest in development programs and dwindling trend of fund through different donors.
United States security and non-security aid to Afghanistan had dropped from a high of US$6.2 billion in 2011 to US$4.5 billion in 2020. In its 2020 aid budget, Australia cut its development assistance to Afghanistan from AU$80 million in 2019-20 to AU$52 million in 2020-21.
Donors started discontinuing funding to specific projects. For instance, ICRC and Handicap International discontinued funding to Maiwand Regional Hospital in Kandahar and Kandahar Rehabilitation Center in early 2021.
SEHATMANDI, a performance-based financing mechanism, which remunerates implementing NGOs depending on whether health facilities reach their agreed target, and which was the backbone of our health system, had funding assurance from the World Bank for almost one year, ending in July 2022.
Protracted conflict and security measures in response to ongoing threats to health facilities and donor agencies had a negative impact on service utilisation in different parts of the country. The system was suffering from a double burden of unavailability of infrastructure in rural parts of the country as well as low utilisation of services in areas where the available infrastructure was affected by high profile security measures undertaken by national and international stakeholders.
Humanitarian-development nexus
Lack of attention to the humanitarian-development nexus in health programs has caused wastage of a great deal of resources during the emergency phases, undermining the impact funding could have either in preserving the existing infrastructure or paving the ground for upcoming development programs.
In Afghanistan of 2021 – where billions of US dollars were invested in development programs, many of them already finished while several others were in in progress when the regime collapsed – the solely humanitarian approach of the international community endangers the sustainability and effectiveness of programs that are already finished or in progress.
Both in theory and in practice, humanitarian aid focuses on short term and immediate needs after the crisis. Its purpose is not system building, but to save lives and address people’s immediate needs. Sustainability is always an issue.
It could only be sustainable and effective in the longer term if humanitarian aid was connected with development initiatives. In contrast to humanitarian aid, development aid focuses on the longer term, systemic issues faced by poor nations and shocked systems like the Afghanistan health system.
The purpose of existing efforts should not only be on provision of emergency kits, or water bucks, but on systemic issues and improving the economic, political and social development to ensure sustainability of what we do today.
Otherwise we will lose what the health system has in hand as the result of last 20 years of investment and will need to re-start from scratch in 2024, which will double the costs in the face of dwindling funds and emerging priorities.
As an example, in Afghanistan, after two decades of active contribution of international development agencies and establishment of the health system through which the population witnessed remarkable improvements in health indicators through SEHATMANDI program, the program is now replaced by Health Emergency Response (HER) project by UNICEF.
Replacement of SEHATMANDI with HER is a clear indication of the disconnect between humanitarian and development initiatives and it puts the achievements made during last two decades at risk.
HER is focused on providing basic primary health care with no strategy on how to sustain it in the longer term beyond 2024, how to integrate the newly established health facilities by many INGOs in different corners of the country into the national health system.
HER does not address systemic issues such as financial sustainability, current burden of disease, access issues, and many other related challenges. The simple end result of HER will be closure of many of the new established health facilities in 2024, increased level of NCDs, inequitable health services, and increased expectation at social level which could not be met by the then health ministry.
We live in a world where humanitarian crises are occurring in the context of protracted conflict and violence. It is important that humanitarian and development organisations find a common ground where the Humanitarian-Development Nexus could be realised in practice.
Otherwise, the ongoing short-sighted project-based approach going on around the world, especially in the case of Afghanistan, puts at risk the achievements of decades of investment by taxpayers in the development of the health sector.
As well, it facilitates corruption, and a lack of trust toward effectiveness of international aid agencies and intentions of donor countries.
Key questions
Health systems and population health are at extreme risk in conflicts such as those experienced by the people of Afghanistan.
After experiencing protracted conflicts in different parts of the world, including in Afghanistan, and see the suffering of millions, especially women and children, and billions of dollars invested in addressing the needs of the victims that could have been used instead to improve safety and wellbeing for mothers and children, I have two questions for the global community.
Firstly, have we learned from our past? Isn’t it time to rethink and reassess our political agendas and join forces in building peace instead of fuelling conflict, for which we all will pay the price.
Secondly, is the global community able to continue with the increasing trend of the need for humanitarian aid in the face of the escalating level of protracted conflicts?
I urge the global community, local leaders and international institutions to stick to your verbal commitments and values, and utilise any possible means to ensure peace and health for humanity. Do not allow political and economic greed to trash the prosperity of poor and innocent mothers and children anymore.
Let the white gown heroes of the health community take the lead, ensure health, connect hearts and stimulate smiles on the faces of mothers and children in Afghanistan, Syria, Ukraine, Iraq and across the world.
We must take action before it becomes late and the flames of the conflict burns us all together. For the global health community, this is the time to utilise our potential power and build bridges for peace. We can do what the politicians failed to do across centuries: we can connect people, communities and nations.
Author details
Dr Wahid Majrooh is the Former Minister of Health of Afghanistan (in 2021), previously served as Deputy Minister for Healthcare Service Delivery, Senior International Relations Advisor and Technical Advisor to the Health Minister. He has worked at different senior positions with national and international institutions including the Afghan Government, United States Embassy, USAID, EU, and World Bank. He is a medical doctor and has two Masters Degrees in Global Health Policy, and more than 14 years of experience in leadership, global health, health systems strengthening, diplomacy, strategic communication and health service delivery to under-served communities. He led the fight against COVID-19 in Afghanistan and was the only senior Government official and political figure who stayed in the country after 15 August, 2021, risking his life to continue leading the health sector for another 1.5 months to avoid disruption of service delivery. He currently sits on the WHO’s Executive Board and is CEO and Founder of a Geneva-based organisation, the Afghanistan Center for Health and Peace Studies.
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