“For years we’ve struggled, studied and worked in the most difficult situations. But now we must witness all our achievements vanish before our eyes. And the health system we worked so hard to improve might collapse” says Dr. Freba Azizi, HealthNet TPO Programme Manager at the Afghan-Japan Covid 19 Hospital in Kabul, Afghanistan.

Although the situation is dire now, before the takeover by the Taliban, the health system in Afghanistan had made some significant gains. Several NGOs, including KIT and HealthNet TPO, funded by the World Bank and other international donors, worked in Afghanistan since 2002 to improve healthcare services. Between 2002 and 2016, the number of functioning health facilities increased five-fold in Afghanistan.

Maternal mortality fell by almost half, from 1,390 per 100,000 live births in 2001 to 638 in 2017. To make these gains, the international community of donors like USAID, the EU, and the World Bank pooled $150 million annually and made this available to the Ministry of Public Health (MoPH) in Afghanistan. They in turn contracted local and international NGOs to provide health services. In recent years, KIT also contributed to this system as a Third Party Monitor.

On 16 November 2021, HealthNet TPO and KIT Royal Tropical Institute hosted a symposium on the future of the health system in Afghanistan. One of the panellists at the event, Dr Nasratullah Ansari, former country director of Jhpiego-Johns Hopkins University in Afghanistan, elaborated on this. “The focus of assistance for the last 20 years was on maternal and new-born health. As a result of these programmes the number of new-borns and mothers who had access to healthcare grew. Thousands of health workers were trained. Assessments also found an improvement in the quality of care. In addition to the quality of care, the programmes also focused on health systems strengthening – making the health systems resilient and sustainable,” he said.

However, with the World Bank freezing the funds to the Ministry, funding to the NGOs providing these health services is drying up fast. Pashtoon Afzar, founder and advisor to the Afghan Midwives Association, another panellist, said: “The Association did a short survey and found that mothers are dying because there is no oxygen or medication.”

“For instance, the midwives of Nuristan province approached the provincial health team, not to ask for their salary which they haven’t received for a few months but to ask for fuel or wood fires to heat nurseries. Now, new-borns are dying due to cold nurseries. In some places like Kabul, the midwives have had to leave their jobs because there are no supplies. They need a working environment with at least some supplies.”

Speaking at the Symposium from Canada, Dr. Salehi, former Advisor to the Afghan Government confirmed that Afghanistan’s health sector is extremely dependant on international donors. According to him “Data shows that 85% of the total funding has been paid by donors in the past two decades.” He was worried about existing humanitarian funding, “I’m concerned that the humanitarian financing which is happening right now might be too fragmented and burdened with sanctions. The notion of a holistic approach might be forgotten.”

“I’m afraid we don’t have the financing options other than to urge donors to resume their funding. Of course, domestic finances could be an option in the future, but it is not a promising option at all,” he added.

Dr. Majeed, panellist at the event and former Advisor to the MoPH in Afghanistan and former Head of Mission of HealthNet TPO also echoed this. “NGOs have played have an important role for many decades. Now, it is even more critical that they should come together and ensure that healthcare services are provided. Organisations in Afghanistan are also advocating for the continuation of funding through various alliances.”

In terms of more long-term solutions, we might be at a crucial stage that could define future efforts to stabilise health services in the country. According to Dr. Salehi, “The current humanitarian assistance requires a strategic design to ensure local ownership including local resources are considered carefully for future sustainability. If it is not well designed at this stage, the efforts might be messy with numerous gaps and overlaps without a vision for future sustainability.”

Dr Kamil, Programme Manager, Emergency Operations for the Eastern Mediterranean at the World Health Organisation (WHO), joined the Symposium from Egypt and said, “WHO and many UN agencies have decided to stay and deliver as much as they can during this unfortunate period.” That said they too are facing logistical issues. For example, they have not yet been able to establish functional assistance. But they and other UN agencies like the World Food Programme (WFP) have been able to channel essential commodities to different provinces worth about five million US dollars.

There appears to be a glimmer of hope. "As of now thanks to the different partners and donors, we have been able to start the process of stabilisation. From 1st November WHO and UNICEF have agreed, with the support of humanitarian funds, to fund 34 provinces for three months. We are using the same NGOs used under SEHATMANDI," said Dr. Kamil. SEHATMANDI is a multi-donor funded project managed by the World Bank that funded primary and secondary healthcare across all 34 provinces of Afghanistan through a network of NGOs until August 2021.

He also added, "We are in promising discussions with the World Bank, where they will provide funds for WHO and UNICEF to sustain services until the end of June 2022. This gives us and our partners, NGOs and the international community, time to think about the future of the health system in Afghanistan. There is a plan within WHO and UNICEF to brainstorm on what the future of the Afghan health system should be and then we plan to reach out to other stakeholders." Although he didn’t have a clear solution, he hoped that the brainstorms would give rise to a way forward.

The Dutch representative speaker at the panel Marriët Schuurman, Director Stabilisation and Humanitarian Assistance for the Dutch Ministry of Foreign Affairs and former Dutch Human Rights’ Ambassador, cautioned against relying too heavily on humanitarian aid as a long-term solution. “We will not disengage [with Afghanistan], we cannot afford a system collapse. But the question is how.”

The government is in intensive talks with local and international players like Dutch NGOs and United Nations. According to Marriët Schuurman, humanitarian aid went up in Afghanistan even before August because of the rising food security situation. They are also in talks with local NGOs on how they could safely deliver services. Although they have been able to find some short-term solutions through the humanitarian system, she emphasized that humanitarian aid cannot and should not fill the gap. She explained “Humanitarian assistance is only for those in need worldwide, but it can never be a system-wide approach. It is not structural support for practical reasons, because the money we have for humanitarian aid will never be enough and because it is not what it is meant for.” Furthermore, according to her the money allocated to development aid is much more than that allocated to humanitarian aid.

The Dutch Government has been in talks to find channels that could support the system. But those are also temporary solutions and linked to conditions to ensure that the money does not end up with the de-facto Taliban government, to ensure all those who need it have access to it and that those who work in the sector can continue to work safely, particularly the female staff.

Marriët Schuurman also pointed out: “They have to have the functionality that the Taliban does not legitimize itself through the support given by the international community and also because we shouldn’t let them off the hook by taking over a country that they have a responsibility to deliver as well.”

There are several moral dilemmas. But to sum up she said: “For the short-term, we manage through humanitarian funding, for the medium term, till next year we are close to finding solutions to allow us to continue paying salaries and providing supplies. But for the longer term, we really have a challenge on how we can have a system-wide approach to continue basic services to support Afghan organisations without doing harm.”

That said, they have been unable to solve the financing issue, the cash issue, and the fuel situation that Pashtoon Afzar spoke of, nor the logistical one that Dr. Kamil mentioned. They have several operational challenges ahead of them. But the biggest challenge for the Dutch Government is finding creative ways to structurally support health service delivery without legitimizing the Taliban government.

Unfortunately, not just the Dutch Government is grappling with these issues, it is essentially one that all stakeholders keen to contribute to the Afghan health sector are struggling with.

In terms of creative solutions for the longer term we urge the Dutch government and EU to engage with multilateral organisations (UN agencies) and support local NGOs for the provision of health services. We also suggest that UN agencies (e.g., WHO, UNICEF) manage a pooled fund for health service delivery, essentially replacing the World Bank administered fund which was operational until June 2021. The current model already includes third party monitoring which can ensure effective health services delivery and accountability of NGOs. As this symposium demonstrates, we will work closely with the international community and local stakeholders to ensure equitable access to vital healthcare services to the Afghan people.

While we no doubt support the demands for basic freedoms and rights for the Afghan people it should not leave them dying. As Dr. Ansari said during the panel discussion, “Access to healthcare is a basic human right, and this should not be compromised.”

Watch the full symposium on the future of Afghanistan's health system here:

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