Afghanistan Analysts Network – English

Economy, Development, Environment

Between Rhetoric and Reality: Access to health care and its limitations

Lena Langbein Frank Dorner 12 min

While the world’s attention is focused on the withdrawal of international forces and the security handover, people in Afghanistan continue to die because they do not have access to adequate healthcare. The health system is frequently held up as a glowing example of the aid efforts of the international community, and since 2002 much progress has undoubtedly been made. But the rhetoric of many political and military actors about successes in this field diverges significantly from reality. AAN guest authors Frank Dörner and Lena Langbein (*) describe what the organisation Médecins Sans Frontières (MSF) sees on the ground in Afghanistan: growing humanitarian needs due to the ongoing armed conflict and a health care system that cannot keep up with the challenges. Insecurity obstructs access to clinics that are often far from people’s homes to start with; the supposedly ‘free’ system charges fees that poor Afghans cannot afford; and the situation for women is even worse, due to a lack of skilled female personnel, particularly in rural areas.

Violence escalates humanitarian needs

Afghanistan is a country at war: 2013 was reportedly the second most violent year for civilians since the US-led NATO military intervention began in 2001. According to the UN, civilian casualties increased by 14 per cent compared to the previous year, and figures rose again in the first six months of 2014 (for an analysis of latest figures, see here). Due to the armed conflict, an estimated 680,000 people are internally displaced in Afghanistan; some 2.6 million Afghans are currently refugees in neighbouring countries. On top of death, injury and displacement, Afghans must contend with poverty, food insecurity, malnutrition and disease. An estimated one in ten children dies before the age of five, mainly from preventable diseases. Official statistics like the National Risk and Vulnerability Assessment (NRVA) for Afghanistan reveal that 36.5 per cent of the population cannot meet their basic requirements such as access to food, clean water, clothing and shelter.

Afghanistan’s ongoing armed conflict aggravates the humanitarian health situation in two ways: directly and indirectly. It directly causes death, injury or suffering that increases medical needs, but it also maims and kills indirectly by impeding access to healthcare. A survey involving more than 800 patients and their caretakers in the four hospitals where MSF teams are working – in Helmand, Kabul, Khost and Kunduz provinces – over a six-month period in 2013 found that one in four of the people interviewed (29 per cent) had experienced violence or knew someone who had experienced violence in the preceding year. A similar number (23 per cent) knew someone, in their family or village, who had died as a result of violence in the preceding year. In all locations, the ongoing war had been the main cause of violent death during the previous year, with civilians repeatedly caught up in direct attacks, crossfire, bombings or landmine explosions (read the full report here).

These war activities also create dramatic barriers that people must overcome to reach basic or life-saving medical assistance. The MSF survey shows that people die because they are not able to access healthcare in time. One in five of those interviewed (19 per cent) reported that a family member or close friend had died, within the preceding twelve months, as a result of their inability to access a medical facility or a doctor. Even, when not the main reason, the conflict was always a major contributing cause of the inhibited access to health care. Other major barriers were lack of money, the high cost of treatment and medicine and the often long distances to the nearest clinic.

Long distances and high costs

According to the World Bank, the number of health facilities in Afghanistan increased from 496 in 2004 to 2,074 in 2012. But although the number of health facilities increased considerably over the past decade, people interviewed say there are still too few affordable or properly functioning health facilities close by. Many of those interviewed described the long and dangerous journeys they had to make to bring a sick or wounded relative or a woman in labour to an adequate clinic or health post. In Kunduz for example, one quarter of the war-wounded and seriously injured patients had travelled between two and six hours by car before reaching the MSF trauma centre. Before MSF opened the trauma centre in 2011, people suffering from severe injuries were forced to make the even longer and more dangerous journey to Kabul or Pakistan, or visit expensive private clinics, to receive the specialised care they required.

These accounts are in sharp contrast to official figures: according to the NRVA, today more than 90 per cent of the Afghan population are able to reach the nearest health post within less than two hours. It has repeatedly been claimed, that 85 per cent of the people in Afghanistan now have access to healthcare compared to nine per cent in 2001 (see for example here).

Indeed, the majority of those MSF interviewed said that some form of health facility, whether public or private, existed within an hour’s travel of their homes. However, bear in mind three points. First, urbanisation pushes people towards towns and cities. Thus, the fact that figures show that more people now live closer to a health facility do not necessarily mean that the number and the quality of health facilities have increased in all locations. Second, health statistics, like other statistics from Afghanistan, are notoriously unreliable, as data from the most remote and least secure areas are often excluded. This introduces a persistent bias that is likely to contribute to overly positive country averages. The overly positive claims are also at odds with research conducted for the International Committee of the Red Cross (ICRC) in 2009, which estimated that more than half of the population had little or no access to basic services, including healthcare. In a countrywide survey of the Asia Foundation in 2013, when asked to identify the biggest problems facing Afghanistan at the local level, healthcare was cited by 13 per cent of the respondents.

Third, a health centre that exists is not necessarily one that is used or that functions well in practice. In fact, the survey found that the majority of those interviewed had not gone to the closest public health facility during a recent episode of illness in their household. It was found that people often avoid the closest health post because it lacks consistently present qualified staff, quality drugs, treatments or services – all characteristics that had contributed to the bad reputation of public health services in the past.

Instead, people prefer to make long journeys to reach distant clinics that they hope will offer better care. An absence, or a perception of a lack of treatments and services sometimes even pushes people to seek care in other countries. Of those interviewed by MSF in Kabul, one in five (21.6 per cent) had travelled outside Afghanistan to seek the care they required, most of them (90 per cent) heading to Pakistan. In Kunduz and Khost, almost one in ten and one in twelve, respectively, had gone to Pakistan to seek treatment for an illness of someone in their household in the preceding three months. The long distances people must travel to seek care not only delay the provision of urgently needed treatment, but also force them to undergo perilous and costly journeys.

As pointed out in the report, besides war, insecurity and long distances, high costs are also an important barrier to access healthcare for many people in Afghanistan; travelling to distant, better health facilities often increases expenses, forcing families to become indebted to provide treatment for relatives. These include non-medical costs for transport to and from the health facility, accommodation and food, in addition to the actual medical costs. Despite the fact that healthcare should be free of charge, as promised under the national free care policy (article 52 of the Afghan constitution), this is not the case in many public facilities. Instead, people must pay for drugs, doctor’s fees, laboratory tests and in-patient care.

According to the survey carried out by MSF, medication ranked as one of the highest costs people incurred. Across all four locations, more than half (56 per cent) of patients who had visited a public facility reported that they ended up paying for all the medication they needed. The NRVA also found that for many households, health expenditure may be prohibitive, especially if advanced and prolonged treatment or hospitalisation is required. According to the NRVA’s figures, less than one quarter of all households had spent money on in-patient care – but if costs were paid, they were usually large, with an average expenditure of 34,000 Afghani (around 580 USD). Expenditure on out-patient care was considerably lower, with a mean of 1,500 Afghani (around 25 USD) by all households, but was made twice as often – by 51 per cent of all households – compared to in-patient care. Other health-related expenditures were smaller but more frequent (63 per cent of households).

Overall, households in Afghanistan spent on average more than 9,000 Afghani on healthcare (around 150 USD). It is notable that urban households had a significantly higher level of expenditure than rural households, which is likely related to lower urban poverty levels and better access to health services. In a country where, according to the World Bank, more than one third of the people are living below the national poverty line of less than 1.25 USD per day, such expenditures can be crippling.

Gaps in the health system

Although many of Afghanistan’s health indicators are still poor in international comparisons, the Afghan health system is showing signs of recovery from a collapse that happened over the recent decades of conflicts. Significant improvements have been made in the post-Taleban period, especially after the adoption of new health policies and a strategy to deliver a so-called Basic Package of Health Services (BPHS). (1) But despite positive steps – such as the increasing number of health facilities, both public and private; the implementation of outreach programmes by the Ministry of Public Health; and the improving maternal and child health indicators – significant gaps remain when it comes to the delivery of good and affordable healthcare.

During the interviews people complained about the poor quality of the public health system, including of staff and services; lack of appropriate drugs; and an improperly functioning referral system. They reported that often they had to wait a long time to be treated or that health facilities were open during hours that did not correspond to medical needs. For instance in clinics that are open only in the mornings, women experiencing complications during labour at night or other times of the day or wounded patients who need immediate medical care are not cared for in time.

Women and girls face specific barriers to accessing proper and timely health services, both for themselves and their children. These include, due to low literacy rates, a lack of knowledge of health problems and practices and restrictions of their movement and their access to money. Women, moreover, usually must be accompanied by a male, which doubles travel costs and makes the financial burden of accessing health services larger for women than for men.

Afghanistan, moreover, continues to be one of the most dangerous places in the world to give birth. But there are still too few midwives and female doctors and nurses. According to UNFPA, in 2012 Afghanistan had 3,500 midwives (compared to 2001, when it had around 300), and 6.5 million women of reproductive age. In Afghanistan only 23 per cent of the needs of pregnant women and newborns were met. In comparison, in Pakistan, 42 per cent of women’s and newborns’ needs are met (see The State of the World’s Midwifery report). In many parts of Afghanistan, especially in rural areas, women do not have access to essential obstetric care. Families often do not allow their women to be treated by male doctors, while female health workers still only make up around 25 per cent of all healthcare personnel. It also has to do with the uneven distribution of health workers. According to research carried out by Save the Children in 2013, there are on average 4.5 health workers per 10,000 people in remote and rural provinces, compared with 16 per 10,000 in the more urban provinces. According to the same briefing paper, the World Health Organization (WHO) estimates that at least 23 doctors, nurses and midwives are needed for every 10,000 people in order to deliver basic healthcare to all. The Afghan public health sector has an average of 4.8.

The low quality of public health services partly has to do with the current policy of awarding BPHS contracts to the lowest-cost NGO provider, which risks undermining the quality of services provided.

Managing clinics by remote control

Informal fees and corruption are another worrying problem, considering that costs pose an important barrier to access healthcare. People reported that they often have to pay bribes in order to be seen by a doctor in a public clinic. Others spoke of doctors in public clinics pushing people to their after-hour private practice, saying that it was better equipped. People also regularly complained that public clinics in remote areas sold their drug supplies to pharmacies, so that patients had to buy them instead of receiving them free in the clinic.

As a result, the quality of public services is often perceived to be low, even if this is not always the case. For instance, an MSF assessment of the public clinics in Lashkargah district showed that general primary healthcare provision appeared to be functioning well. At the time of the visits, all public health centres were open and providing consultations free of charge and seemed to have adequate levels of patient attendance. But distrust in the public health system causes many people to prefer private clinics and private doctors, who are perceived to be better in terms of quality. Yet, the interviewed showed that this view of in the private system is not necessarily justified. Many reported overprescribing, misdiagnosing and even malpractice and medical mistakes by private practitioners. Many private providers seek to benefit from the bad reputation of the public sector and ask high fees for their services. It is therefore essential that public health facilities offer quality care as an accessible and affordable alternative.

Whether bad conduct by staff in public clinics or corruption and abuse of patient trust by private practitioners, many of malpractice are enhanced because – due to conflict and insecurity – many clinics can be managed and monitored only by remote control and reports (submitted, for example, to the headquarters of NGO service providers in Kabul) are difficult to check.

Healthcare and the politics of aid in war

As shown, a focus on improving both coverage and quality of health facilities is necessary, particularly in the least secure areas, where basic and life-saving medical care is often non-existent and access of humanitarian organisations to the most vulnerable people has been compromised by insecurity and by the involvement of military actors in activities traditionally carried out by aid agencies.

Over the past decade in Afghanistan, the boundaries between humanitarian and military actors have often been blurred, with serious and lasting consequences for the perception of the neutral and a-political character of aid.

Throughout much of the war the biggest donor countries were also involved in combat and often directed their aid in line with their political and military ‘stabilisation’ objectives, as part of a counter-insurgency strategy (COIN). Military commanders directed billions of dollars to development projects through Provincial Reconstruction Teams (PRTs) which consisted of a mix of military, diplomatic, development and civilian components. By accepting funding earmarked for places where troops from their donor countries were deployed, NGOs were potentially seen by armed opposition groups as choosing sides in the war, while international actors like NATO often considered NGOs part of the ‘soft power’ efforts of a nation-building project (more about this here,  and AAN analysis here).

Thus, aid became perceived as aligned with one side of the conflict. Decisions on where and how to provide assistance were often based on military considerations at the expense of people’s most pressing needs, while many projects carried out by military actors had limited impact. Moreover, when health and other public services are linked to military or political agendas – as was the case when hospitals were used as registration and polling centres during the elections or even as temporary bases for military operations – health personnel and patients are exposed to increased risk.

If humanitarian aid is not perceived as impartial and neutral, aid workers increasingly risk becoming victims of violence. According to the Aid Worker Security Report, incidents against aid workers in Afghanistan have increased by 45 per cent in 2014 compared to the previous year. Afghanistan remains the country where they counted, by far, the most attacks against aid workers (81, compared to 43 in Syria, which is ranked second).

After 2014: Securing neutrality, access and an adequate response

Uncertainties abound about what the future will bring for Afghanistan, but predictions about security cannot be very optimistic. Yet, healthcare provision is currently insufficiently geared to meet both the existing and rising medical and emergency needs. Since 2002, important progress has been made, which should be built on – focusing on improving both coverage and quality of health facilities, particularly in the least secure areas where basic and lifesaving medical care is often non-existent, prohibitively expensive or inaccessible. Considering the volatile security situation outside provincial capitals, great efforts should be made to allow existing rural health facilities to remain open and properly functional. Better evaluation and monitoring on the ground would help.

The destruction and disruption of services has disproportionally affected those living in militarily contested areas, while insecurity and limited access to these communities, by both the authorities and humanitarian agencies like MSF, complicate an adequate response. Ensuring that proper emergency care is brought to people will be challenging, but is essential and will involve negotiating access with all sides of the conflict. This need to improve access to insecure areas underlines the importance of both pragmatic and principled approaches and the need to provide effective basic services and humanitarian aid in a neutral, impartial and independent manner. Aid provision must thus be untangled from political and military agendas, and should focus on addressing the actual needs of the people.

With donor and media interest in the country predicted to wane in the near future, a renewed focus on the real experiences of the Afghan population will be essential. Any desire to package Afghanistan as a simplified political or military success story, risks masking the reality of the ongoing conflict and of the suffering of hundreds of thousands of people who struggle to survive and who still do not have access to adequate medical care.

(1) The Basic Package of Health Services (BPHS) was introduced by the Afghan Ministry of Public Health and donors (the World Bank, USAID and the European Commission) in 2003. It encompasses a standardised package of basic services to be delivered in all primary healthcare facilities consisting of: maternal and newborn health, child health and immunisation, public nutrition, communicable diseases, mental health, disability and the supply of essential drugs. It is implemented by subcontracting services out to Afghan and international NGOs.

(*) The authors:

Frank Dörner was General Director of Médecins Sans Frontières (MSF) Germany from May 2008 to June 2014.

Lena Langbein is a freelance journalist and media consultant and has worked with MSF for many years. In 2014 she organised MSF’s Spring Conference “Between Rhetoric and Reality – The Humanitarian Situation in Afghanistan.”

MSF is a medical humanitarian organisation that operates under the principles of independence, impartiality and neutrality. In Afghanistan MSF runs a surgical trauma centre in Kunduz in the north and a maternity hospital in Khost. It supports the Afghan Ministry of Public Health in the Ahmad Shah Baba Hospital in eastern Kabul and in Boost Hospital in Lashkargah, in Helmand in the south. In all locations, MSF provides quality medical care free of charge. In Afghanistan, MSF relies on private funding only and does not accept funds from governments for its work.