Responding to existing and emerging healthcare challenges in Afghanistan


Syed Zafar Mehdi

The Afghan government, with the help of its international partners, has made indefatigable efforts to create a functional healthcare system in Afghanistan but there are still many hurdles to cross and many critical tasks to accomplish

The decades of war and turbulence have taken a heavy toll on life in Afghanistan. It has also quite severely affected the capacity of concerned agencies to respond to critical public healthcare challenges.

According to World Health Organisation (WHO), United Nations public health arm, Afghanistan’s health status is one of the worst in the world with some of the health indicators three to five-fold higher than in neighboring countries.

While the local and international healthcare experts, equipped with skills and machinery, have played an instrumental role in setting up healthcare infrastructure after 2001, there are still many hurdles to cross and many critical tasks to accomplish.

Even though there are about 2170 healthcare centers across the country, the quality healthcare service is lacking, forcing a large majority of Afghans to fly abroad, mostly to India and Pakistan, for medical treatment.

Oxfam, a global aid and charity organization, in its 2013 annual report stated that 25 percent population in Afghanistan still has no access to healthcare services. Ministry of Public Health earlier this year said one in every ten children in Afghanistan loses his or her life before reaching the age of five.

The public healthcare challenges in Afghanistan manifest itself in multiple ways. The lack of healthcare infrastructure, shortage of skilled healthcare professionals, lack of robust government policy, sub-standard drugs in the market, precarious security environment are some of the major hurdles.

While lot of money has gone into establishing tertiary care hospitals across Afghanistan, the standard and robust healthcare infrastructure is still missing in many parts of the country

The former president, Hamid Karzai, who accompanied his wife to India for medical purpose earlier this year, was often criticized for not paying enough attention to healthcare sector in Afghanistan.

His predecessor, Ashraf Ghani has looked comparatively proactive in the early part of his tenure. His wife, Rula Ghani, has publicly expressed concern over the abysmal quality of maternal healthcare system and shortage of female healthcare professionals in Afghanistan.

Healthcare challenges and the response of government
In a post-conflict country, the challenges of creating a functional healthcare system are always massive. Over the past 13 years, the Afghan government, with the help of its international partners, has made indefatigable efforts to rebuild the healthcare system that was lying in ruins following the years of war. While lot of progress has been made, many challenges continue to persist.

According to observers and medical practitioners, health status has improved considerably over the past 13 years, but lot more needs to be done. “We have come a long way in past 13 years in terms of healthcare infrastructure and service delivery,” says Dr. Musa Wardak, orthopedic surgeon at Shinozada Hospital in Kabul. “But there are still many loopholes that need to be plugged and the onus lies on all stakeholders, including the government and private sector.”

While lot of money has gone into establishing tertiary care hospitals across Afghanistan, the standard and robust healthcare infrastructure is still missing in many parts of the country. Consequently, a large majority of population living in provinces still have no access to quality healthcare services.

The shortage of skilled healthcare workforce makes the matters worse. “We lack latest procedures and support facilities here and doctors don’t always have the requisite skills to deal with emergency medical cases,” says Dr. Shapoor Musa, a Kabul-based doctor.

A large majority of Afghan patients fly to India for advanced medical treatment. “Patients from Afghanistan who have come here have achieved good results and are now referring their friends and relatives too,” says Dr. Yash Gulati, senior consultant at Apollo Hospital, New Delhi.

In early 2002, soon after the establishment of an interim government, the Ministry of Public Health announced the Basic Package of Health Services (BPHS) to ensure basic healthcare services reach to majority of population in Afghanistan.

The scheme has been instrumental in the delivery of basic healthcare services, especially in provinces, but many challenges persist. “It was a good step to ensure basic healthcare services are provided to citizens, but we still have not done enough to provide primary healthcare services,” says Dr. Parvez Meeri, who works at Nasir Khusrao Balkhi Hospital in Kabul.

The main challenges in rebuilding healthcare system in Afghanistan, according to Dr. Ruhullah Rasik, doctor at Indira Gandhi Hospital in Kabul, include lack of infrastructure, abysmal security, economic problems, lack of access to healthcare facilities, lack of coordination between government officials and healthcare providers, shortage of skilled healthcare professionals, especially female doctors and mid-wives.

“It is important to address these concerns to have healthcare system that is at par with other countries in the region,” he says.

Impact of war on healthcare
The security situation in Afghanistan continues to be dangerously volatile. The armed insurgents, even 13 years after the intervention of international community, refuse to retreat or surrender. This insecurity, according to observers, is the biggest impediment in delivery of healthcare services.

Landmines pose biggest threat to women who have to reach hospital or children who have to go to school. They also damage roads, like in Kandahar province, making it difficult for ambulances to reach the remote areas. Every month, hundreds of expecting mothers and other critical patients succumb before reaching hospitals.

Afghanistan has earned the dubious distinction as the country with most landmines and improvised explosive devices (IEC), which make it difficult for health workers to reach far-flung provinces. Many local and foreign health workers have been the victims of landmines and IEDs and many of them have been kidnapped by armed insurgents for ransom. “It is unfortunate that even doctors have been at the receiving end,” says Dr. Fazal Ahmad Nawabi, Kabul-based medical consultant.

Afghanistan has earned the dubious distinction as the country with most landmines and improvised explosive devices (IEC), which make it difficult for health workers to reach far-flung provinces

According to officials in the Ministry of Public Health, the cases of polio have alarmingly shot up in recent months following the draconian ban on anti-polio vaccination drive by armed insurgents in a number of provinces.

In restive southern Helmand province, local insurgents announced a ban on anti-polio vaccination campaign in March this year, leaving many polio-affected children at high risk. Many fresh cases of polio have been reported from this province.

After Helmand, according to reports, insurgents also banned the anti-polio vaccination drive in eastern Nangarhar province recently, apparently in protest against government-imposed ban on motorbikes in some parts of the province. Dr. Moqadas Meraj, Deputy Director of Nangarhar Civil Hospital, says the insurgents have made their demands clear.

“Taliban have asked the government to lift the ban on motorcycles but the governor of Nangarhar province has turned down the demand,” she said. According to Dr. Meraj, about 30,000 children have been deprived of anti-polio vaccination drops because of the ban.

Healthcare professionals, especially those affiliated with foreign NGOs, have often been targeted across the country. In April this year, an American doctor and his two friends were killed by an armed insurgent masquerading as a security officer at Kabul-based Cure International Hospital, which is operated by a U.S.-based charity organization.

“The attack was a grim reminder that even foreign doctors who save precious lives are not safe in this country,” says Dr. Munir Samim, Kabul-based medical practitioner.

Maternal and child healthcare
Addressing a gathering of female health workers in Kabul recently, organized by Afghan Society of Obstetrician and Gynecologists (AFSOG), First Lady Rula Ghani expressed concern over the abysmal quality of child and maternal healthcare system in Afghanistan, and emphasized on increasing the number of female health service providers.

According to a report by Save The Children, an international children’s charity organization, at least 3,000 newborn babies die daily within 24 hours of birth in Afghanistan. The report states that 1 in 34 babies die within 24 hours of birth daily and main reasons are premature birth, prolonged labor during pregnancy, infections and high blood pressure.

Medical experts say the newborn babies lack proper care after birth in Afghanistan, which exposes them to medical bugs. “Newborn babies need proper care and attention which is lacking here,” says Dr. Samim. “We have a children’s hospital in Kabul, but when you compare the facilities there with hospitals in neighboring countries, it is not good enough.”

Maternal mortality rate, which was once the highest in the world, has significantly improved in recent years.  According to the State of Afghanistan’s Midwifery 2014 report released recently by the Ministry of Public Health and the Afghan Midwifery Association, there has been remarkable progress in improving the quality of maternal and reproductive health services in Afghanistan.

However, only 23 percent of the needs for maternal and reproductive health services are currently met in Afghanistan. According to the report, a four-fold increase in investment in midwifery is required over the next 15 years to meet 60 percent of the needs for maternal and reproductive health services.

According to Ministry of Public Health, in 2002, there were only 467 midwives in the country. Today, there are almost 4,600 midwives working in Afghanistan who have played key role in bringing down the maternal mortality rate from 1,600 to 327.

According to the United Nations, the estimated number of people living with HIV in Afghanistan is around 5000 but only 30 percent of them have been tested

“There is a need to increase the number and efficiency of educated professional midwives and improve recruitment policies, career pathways and retention policies,” says Dr. Annette Sachs Robertson, UNFPA Representative for Afghanistan.

Ahmad Jan Naeem, acting Minister of Public Health, says lack of security is a major problem for female doctors in provinces. “We have provided them additional facilities and increased their salaries, but the problem of security is a big challenge,” he says.

Emerging healthcare challenges
While existing healthcare challenges persist, some new and potentially dangerous health challenges have emerged of late. On December 1, which marks the World AIDS Day, Ministry of Public Health announced that the cases of HIV in Afghanistan have shot up by 10 percent.

According to Ministry officials, a total of 1694 cases have been registered by the government monitoring systems, but the actual number is likely to be higher.

Mr. Naeem says the outbreak of HIV is primarily due to lack of awareness about HIV virus, use and abuse of drugs, poverty, illiteracy and growing number of immigrants coming from Iran. “Ministry of Public Health has set up many prevention centers, consultancy centers and curative centers to check the outbreak of HIV in the country,” he said.

According to the United Nations, the estimated number of people living with HIV in Afghanistan is around 5000 but only 30 percent of them have been tested. Urmila Chanam, a public health professional and gender rights activist, believes the rise in HIV cases could be due to low number of people going for testing, which makes early detection impossible.

“It is high time that the accurate estimates of the most-at-risk-populations are etched out at the earliest so that policies, interventions, planning and implementation could be executed at quick speed to arrest the spread of HIV in Afghanistan,” says Ms. Chanam. “It would be a good strategy to adopt the rapid scale up model adopted by countries like India to boost its coverage of HIV response from 8 provinces at present to all the 34.”

Another emerging health challenge is the rising number of polio cases in some provinces. According to Ministry of Public Health, fresh polio cases have been reported following the ban on anti-polio vaccination drive by Taliban insurgents in some provinces like Helmand, Nangarhar and Khost.

Some polio cases have also been identified among refugees from northern Waziristan who have settled in Khost province. According to Public Health Department officials in Khost province, the refugee children have not been administered polio vaccination and that makes them more prone to this disease.

The battle for eradication of polio in Afghanistan – one of the only three countries besides Pakistan and Nigeria on World Health Organization’s (WHO) list of countries – continues. According to WHO, both Nigeria and Afghanistan present grim cases as the number of cases creep up. In February this time, Kabul recorded its first polio case in last 13 years.

Afghan Red Crescent Society (ARCS) recently dropped another bombshell. According to ARCS, heart diseases in Afghan children have alarmingly increased of late. A country-wide study conducted by ARCS showed most cases of heart disease in young children coming from eastern Nangarhar province and the most commonplace disease is holes in the heart, which according to medical practitioners is a congenital heart defect.

“ARCS assessment shows the disease has assumed alarming proportions, especially in Nangarhar province, and most of the patients have no access to medical care,” said Sarma Afzali, media officer in ARCS. According to her, most of the families cannot afford the treatment, and they do not pay much attention to daughters who suffer from these ailments.

Future of healthcare system 
Healthcare system in Afghanistan has seen significant improvement over the past 13 years, but to establish a functional and robust healthcare system, it is important to pay attention to primary healthcare needs of people, believe experts.

At a time when international community is getting ready to pull out of Afghanistan, there are speculations that the country will be abandoned and the healthcare industry will collapse.

“If anyone is of the impression that the health industry will collapse post 2014, following the drawdown of international forces, they are mistaken,” says Dr. Abdul Habib Azizi, who works at Helmand Military Hospital. “The gains of past 13 years are irreversible.”

(First published in Afghan Zariza)

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About Zafar Mehdi
Maverick journalist, irreverent rebel, travel freak, cricket junkie, reluctant fundamentalist, student of life, dreamer, believer.

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