2022

RE PORTPERSISTENTBARRIERS TOACCESSHEALTHCARE
IN AFGHANISTANThe Ripple Effects of a Protracted Crisis and a
Staggering Economic SituationPERSISTENT BARRIERS TO ACCESS HEALTHCARE IN AFGHANISTANCONTENTS
03 Executive summary
05 Introduction
08 Methodology
10 MSF key activities in Afghanistan

during 2022

13 The hardships of a protracted

economic crisis

17 Soaring medical and humanitarianneeds and a struggling healthcare
system24 The protracted struggle of anunder-resourced healthcare systemcompounded by further challenges

28 Conclusion

2

PERSISTENT BARRIERS TO ACCESS HEALTHCARE IN AFGHANISTANEXECUTIVE SUMMARY

This research finds that Afghans still struggle
with access to healthcare due to a combinationof increased widespread poverty, and a further
weakened public health system: factors thatexacerbate the already existing health needs. As
highlighted in the past, the healthcare delivery
model in Afghanistan has not been sustainable,
remaining under-funded and under-resourced,
lacking qualified personnel, equipment, medicinesand medical supplies. The economic, banking
and liquidity challenges are at the heart of thecurrent humanitarian crisis in Afghanistan andgreatly contribute to the difficulties people facein accessing and affording essential services,
including healthcare. The unmet medical andhumanitarian needs continue to soar as the social,political and economic situation continues todeteriorate.

Between Rhetoric and Reality. The Ongoing Struggle to Access
Healthcare in Afghanistan (February 2014); Reality Check.
Afghanistan’s Neglected Healthcare Crisis (March 2020); The
Continued Struggle to Access Medical Care in Afghanistan (May2021).
1© Oriane Zerah, 2022

In 2014, 2020 and 2021, the international medical
humanitarian organisation Médecins Sans
Frontières (MSF) reported on the recurrent barriersof access to healthcare in Afghanistan, with a focus
on why access was obstructed or delayed. The reportfound that socio-political and economic factors
were the strongest determinants. Some of the mostcommon barriers that MSF highlighted were the‘high costs and lack of money.’1 This referred to both
directly related healthcare costs and indirect costs,
such as transport and accommodation. In 2022,
MSF conducted additional research in the form of
this report, to see if the situation has changed. This
report presents statistics and accounts resulting
from research conducted between May and August2022 with over 200 patients, caretakers, MSF andMinistry of Public Health (MoPH) staff in Kabul,
Kandahar, Khost, Helmand and Herat provinces.

Saddiqulah has developed pneumonia and severe sepsis after sufferingfrom measles. He is receiving treatment in the paediatric department of
MSF-supported Boost Hospital in Lashkar Gah, Helmand.

As such, the main obstacle to accessing healthcare is
still the cost, according to 87.5 percent of our surveyrespondents, an increase of 18 percent in comparison
to 2021 survey’s findings. Understandably, people
still refer to conflict, security and violence as
ongoing challenges. This is, in part, because
the survey actively asked information about thepreceding 12-month period, but also because formost Afghans, the consequences of living throughdecades of war will continue to impact their lives for
an indefinite period, including their perceptions ofbarriers to accessing healthcare.
The report spotlights the extra challenges faced by
women. They have been struggling with additional
obstacles, such as the socio-cultural mobility
constraints – like requiring male accompaniment3

PERSISTENT BARRIERS TO ACCESS HEALTHCARE IN AFGHANISTANOver the last year, in response to healthemergencies and outbreaks and the overall
increased health needs of people in the country,
MSF has been compelled, once more, to add toand expand its activities. In 2022, MSF increased
its scope in Bamyan, Helmand, Herat, Kunduz andKabul (Maiwand) in order to respond to the sharp
increase of measles cases. In Boost hospital inHelmand and in Herat Regional Hospital, MSF
has also increased the number of beds in thepaediatric departments. In Kandahar city, MSF
opened an inpatient therapeutic feeding centre(ITFC), following increased levels of severe acutemalnutrition. Additionally, MSF opened two
new projects: one in Kabul Maiwand Teaching
Hospital supporting the ambulatory and inpatienttherapeutic feeding centres and a temporary
measles response during the outbreak; and theother one in Bamyan Provincial Hospital supporting
the COVID-19 response in addition to measles andother activities.
Increased and sustained funding is essential sothat Afghanistan’s healthcare system remains
functional. The current funding model throughaid organisations with uncertain, insufficient andtemporary funding (often at three to six months
intervals) does not allow for proper long-termplanning and the establishment or revisions of the
public health system and policies, for which the
Ministry of Public Health should serve a central
leadership role. It is equally important to provide
accessible healthcare to Afghans and improve theability of the healthcare system to both respondto emergencies and to be capable of meeting theimmediate medical needs of the population. It is4

required that policymakers, donors and national
and international healthcare actors:
Invest in strengthening service delivery,
especially at the primary level and in the
districts;• Invest in long-term solutions improving
infrastructure of health facilities, as well as
training and technical support;• Promote regular monitoring and increased
accountability.
•

Aid organisations have become the de facto
substitute for the public health sector, a role thatcannot be sustainably filled by international actors
and particularly when it involves decisions affecting
policies and improvements of Afghanistan’s healthsystem. Humanitarian actors should not remain
attached to political constraints, and should nothave to be responsible for keeping Afghanistan’s
health system on life support indefinitely either.

© Nava Jamshidi, 2022

to leave the house – impacting the access to properand timely primary and secondary healthcare. And
access to healthcare is compounded by a shortageof women health workers, that will only worsen
after the authorities' decisions at the end of 2022
to ban women from undertaking higher education
or working for international or national nongovernment organisations.

A mother and her son in the waiting area of MSF’s outpatient
department in the Kunduz Trauma Centre, Kunduz Province,
Afghanistan. On average, MSF teams in Kunduz provide outpatient
medical consultations to 1,400 patients a month.

PERSISTENT BARRIERS TO ACCESS HEALTHCARE IN AFGHANISTAN© Lynzy Billing, 2022

INTRODUCTIONMSF nurse Aziza Khushal checks Shahisto’s vitals signs in the consultation room on the women's side of the Médecins Sans Frontières (MSF)
drug-resistant tuberculosis (DR-TB) hospital in Kandahar city, Kandahar Province, Afghanistan.

After almost 40 years of consecutive armed conflicts,
natural disasters, several epidemics including a
COVID-19 pandemic, Afghanistan is now facing
what appears to be a never-ending humanitariancrisis with staggering economic, political and social
problems. When the Islamic Emirate of Afghanistan(IEA, also known as the Taliban) entered Kabul on
15 August 2021, foreign development funding was
cut overnight. Afghan assets held in the US and insome other foreign countries were frozen, and many
international organisations and diplomats left thecountry. Afghanistan, heavily dependent on foreign
aid for years,2 has been newly struggling in 2022with all the afore-mentioned shocks, and the extra
2
75 percent of public spending was funded with foreign
grants, Afghanistan: Public Expenditure Update.” World Bank
Group, 2018. https://documents1.worldbank.org/curated/
en/696491564082281122/pdf/Afghanistan-Public-ExpenditureUpdate.pdf

challenges of keeping essential services in place
despite the economic-financial consequences of
the current political landscape.
These challenges have further worsened an alreadyweakened and undersized public health system,with the population strongly affected by widespread
unemployment, making it increasingly difficult
to afford and access healthcare in Afghanistan.
For instance, maternal and infant mortality in the
country remain among the highest in the world.3
Casualties from violence have dramatically reducedin comparison to the past, but are still a sad reality,
and other unmet medical and humanitarian needs,
such as malnutrition and measles, continue to soar.
On top of that, the multi-layered Afghan crisis has
3
Maternal mortality: https://data.worldbank.org/indicator/
SH.STA.MMRT?locations=AF; neonatal mortality: https://data.
worldbank.org/indicator/SH.DYN.NMRT?locations=AF

5

placed a notoriously high burden on women,4 andnot because of an inherent vulnerability,5 but more
due to multiple barriers in accessing services andincreased restrictions on participating in public
life, additional to all the challenges impacting mostpeople’s lives in the country.
The withdrawal of NATO and US forces, ended
a 20-year conflict in August 2021, which led to a
general improvement in the security context. Thishas purportedly enabled people to move aroundmore easily than in the past and allowing for easiertransportation of medical supplies in most partsof the country. The safer journey and lack of local
medical care may have contributed to the increasein the number of people coming to MSF healthfacilities. Nevertheless, the higher influx of patients
does not mean they accessed healthcare without
challenges, or that they have not delayed seeking
healthcare until they had no other option. Across
MSF projects in Afghanistan, patients still report
relevant barriers affecting their health-seeking
behaviours, barriers that, for some people, are notpossible to overcome. The journey itself may beless dangerous for most, but it certainly became
more difficult to afford.

© Lynzy Billing, 2022

PERSISTENT BARRIERS TO ACCESS HEALTHCARE IN AFGHANISTAN

Nine-year-old Bibi Fazlia and her father Hamdullah in the female
inpatient ward at the Médecins Sans Frontières (MSF) drug-resistanttuberculosis (DR-TB) hospital in Kandahar city, Kandahar Province,
Afghanistan.

However, the difficulty in affording the trip to ahealth facility – or the economic barrier – is nothing
new. In fact, MSF has been witnessing this for many
years. In 2014, MSF reported about the ‘ongoingstruggle to access healthcare in Afghanistan’ andin 2020 and 2021, MSF was sharing patient andcaretaker accounts of the ‘continued struggle’

MSF sees in its health facilities. In 2022, thefragile status of Afghanistan showcased why these
persistent barriers should have been prevented
from reaching this state and that if no significant
actions are taken to avoid the worsening of this
scenario, the outcomes will be more catastrophic
than they already are.

“Women and girls are differentially affected by crisis. Whentheir rights to move and work are restricted as they are in
Afghanistan, they are disproportionately impacted, especially inaccessing food, healthcare and safe shelter” (Alison Davidian,
CR for UN Women speaking in Gayan District a few days after
the earthquake), June 2022, https://twitter.com/un_women/
status/1541632609557561344?lang=en

For decades, security-violence, cost of the journey
and lack of quality healthcare near home have been
consistent obstacles to accessing healthcare, asreported by MSF patients. But in 2022, the country
has been clearly suffering from the rippling effects
of a crumbling economy, a financial crisis (liquidityand dysfunctional banking system) and cuts inforeign funding.

4

5“Why are women and girls the worst affected by humanitariancrises?”, IPPF, September 2021 (https://www.ippf.org/blogs/whyare-women-and-girls-worst-affected-humanitarian-crises); and“THE WORLD’S BIGGEST MINORITY? Refugee Women and Girls in
the Global Compact on Refugees”, The Forced Migration Research
Network, University of New South Wales (Australia), October
2017 (https://www.unhcr.org/events/conferences/59e5f4447/
worlds-largest-minority-women-girls-global-compact-refugeesextended.html)

6

PERSISTENT BARRIERS TO ACCESS HEALTHCARE IN AFGHANISTAN

MAIN FINDINGS

97.5%

95%

91.2%

said that they have experienced
financial challenges due tospending money on healthcare(20 percent more than in 2021),
as they either had to borrow,
dig into their savings, or sellproperties and household items.

said they had difficulties inaffording food in the past 12
months.

of our survey-respondents
reported decreased income, 15.5
percent more than the 2021 survey.

87.5%

62.5%

of the surveyed respondents
included costs as their mainbarrier to access healthcare,
18 percent more than in 2021.

of the survey-respondents believe
women face worse obstacles
to accessing healthcare incomparison to men.

88%of the respondents either
delayed, suspended or forewent
seeking medical care andtreatments due to the reported
barriers (14.3 percent morethan in 2021), from which 52
percent believe their relative
died due to lack or delayedaccess to healthcare.

45.4%
An average of 45.4 percent of the respondents who have visited apublic or a private facility at least once over the past year were notsatisfied with the service provided, similar to 2021 findings.

7

PERSISTENT BARRIERS TO ACCESS HEALTHCARE IN AFGHANISTANMETHODOLOGYSCOPE OF THE RESEARCH

LIMITATIONS

For the third consecutive year and to continue
shedding light on the persistent barriers tohealthcare access for Afghan people, this MSF
report on access to healthcare in Afghanistan
follows up on the previous two reports, which
focused on Helmand and Herat provinces in 2020
and then on Helmand, Herat, Kandahar and Khost
provinces in 2021. In 2022, MSF focused on thesame provinces from the previous year’s report,with the addition of Kabul.

It must be noted that the results of the survey,
interviews and group discussions cannot be
extrapolated as countrywide results due to thestill relatively narrow sample size and conveniencesampling (as opposed to random sampling)method. The survey data collection focused
exclusively on patients (and caretakers) who
sought treatment at MSF medical facilities anddid not include patients from the wider population
who may have chosen to go elsewhere. A total of
62 percent of the respondents had visited another
health facility (public or private, including nonprofit organisations) before seeking care at MSFrun or supported facilities and around 85 percentof the respondents indicated that over the past
12-month period they had visited at least one
public or private health facility. Meaning that the
majority of the patients surveyed had a non-MSF
related experience with the healthcare system in
Afghanistan.

METHODS AND SAMPLING
Following a larger sample in comparison to
the 2021 report, but still a similar conveniencesampling approach when selecting respondents,
the research information gathering was based on
mixed methods applied between May and August
2022,6 as below:•••

A survey among 160 patients and caretakers(92 women and 68 men) in four provinces(Helmand, Herat, Kandahar and Khost) througha predominately quantitative pre-tested
questionnaire applied in May and June 2022
6 focus group discussions in the abovementioned four provinces between May andAugust 2022
60 semi-structured quality interviews, including
MSF and MoPH staff, but also patients andcaretakers across the five involved provinces
between May and August 2022

Additional information collected:
Health data and indicators from medical
reports of health structures supported by
MSF from January to December 2022 in fiveprovinces (Kabul, Kandahar, Khost, Helmandand Herat)• Literature review•

6
Informed consent was provided by all participants in the survey,
all interviews and group discussions.

8

The research’s survey is focused on the period
between May 2021 and June 2022, with several
questions enquiring on access to healthcare “in theprevious 12 months,” and not exclusively focusedon the period subsequent to the change of power inAugust 2021. This could explain why 57.5 percent of
the survey respondents included conflict/insecurity/
violence within their main barriers to accessing
healthcare in the preceding 12-month period, as
the period between May and June 2021 witnessedhigh intensity of fighting and active hostilities that
impacted people’s mobility and therefore accessto healthcare. The overall improvement in security
and movement restrictions related to conflicts sinceAugust and September 2021 may have contributed
to the increased numbers of patients seeking carein MSF-run or supported facilities, particularly
from areas that were not very accessible until a few

PERSISTENT BARRIERS TO ACCESS HEALTHCARE IN AFGHANISTAN© Nava Jamshidi, 2022

months ago. However, as financial constraints – likethe cost of transport and accommodation – become
even more challenging, and additional restrictions
are imposed or strengthened such as the need for
women to be accompanied by a mahram (a formof chaperone) for their movements, there are still
people who are unable to reach MSF’s facilities, andthe current results might not be able to capture thetrue extent and types of barriers they face.

Bibi Mariam and her mother Moslemeh at the MSF Kunduz Trauma Centre, Kunduz Province, Afghanistan. Bibi was injured in a motorcycle
accident in Kunduz City whilst her father was driving her home.

9

PERSISTENT BARRIERS TO ACCESS HEALTHCARE IN AFGHANISTANMSF KEY ACTIVITIESIN AFGHANISTAN DURING 2022
Médecins Sans Frontières (MSF) is a medical humanitarian organisation, which operates
under the principles of independence, impartiality and neutrality. Since the 1980s, MSF has
provided medical care throughout Afghanistan, in areas under the control of a variety ofpolitical and armed factions. Currently, MSF runs projects in seven provinces with a strong
focus on providing secondary healthcare.

Kunduz

Bamyan
Herat

Kabul

Khost
Paktika

Helmand10

KandaharPERSISTENT BARRIERS TO ACCESS HEALTHCARE IN AFGHANISTANIN BAMYAN,
MSF supported Bamyan
provincial hospital on the
COVID-19 and the measles
response from March till end ofJune 2022. MSF has started tosupport four community healthfacilities in remote rural areas ofthe province, a project focusedon mother and child health, thatis already planned to expand to
up to 15 facilities in 2023.
IN HELMAND,MSF has supported theprovincial hospital in Lashkar
Gah since 2009 and expanded
its bed capacity to a total of 340
beds in 2022 following increased
medical needs.
IN HERAT,
Regional Hospital, MSF has
expanded its support to the
paediatrics department andcontinues to support a clinic in
Khadestan. Until March 2022
MSF was running a 32-bed
COVID-19 treatment centre.

IN KABUL,in April 2022 MSF started
supporting Maiwand Teaching
Hospital for measles with
28-beds and since then it has
increased its support to thepediatric department including
a 34-bed inpatient therapeutic
feeding centre together with
outpatient nutrition care. In
addition, following the closureof the MSF maternity projectin Dasht-e-Barchi, MSF has
been supporting the Afghan
Midwives Association’s pilot
project in the neighbourhood
since November 2021 throughfunding and technical support
for deliveries, antenatal andpostnatal care, as well asfamily planning.

IN KHOST,MSF runs a maternity hospitalwith 60 post-partum and28 neonatal unit beds. We
also support nine healthcentres, including Khost
Provincial Hospital, mostly
through payment of salaries
to increase their humanresources and cover forexisting gaps and to ensure
24/7 access to delivery carefor women in labour, while
investing in strengthening
the referral systems. For six
months in 2022 MSF provided
salary support to all staff in
the COVID-19 ward of the
Khost Provincial Hospital andsupported fuel and food for theentire hospital.

IN KANDAHAR,
MSF runs a Drug-Resistant
Tuberculosis (DR-TB) hospital,
supports the MoPH with thediagnosis of drug-sensitive
tuberculosis at Mirwais Regional
Hospital, Kandahar Provincial
Tuberculosis Centre and Sarpoza
prison. In 2022, MSF expanded
its programme by opening a 40bed inpatient therapeutic feeding
centre (ITFC), to complement theambulatory therapeutic feeding
centre (ATFC) opened by theend of 2021 at the MSF DR-TB
hospital.

IN KUNDUZ,
MSF runs a 61-bed trauma
centre, and established a 75bed measles inpatient ward at
the Kunduz Regional Hospitalfrom March to August 2022, at
one point having to put up tents
because the space inside thehospital was insufficient to treat
the influx of measles patients.
Additionally, in November 2022
MSF opened an ambulatory
therapeutic feeding centre(ATFC) at the District Advanced
Post in Chadara District,following increased needs.
IN PAKTIKA AND KHOST,MSF alongside the NGO
Emergency responded tothe earthquake in June 2022,
donating medicines and medical
material, and providing direct
medical care in Bermal, to both
inpatients and outpatients.

11

PERSISTENT BARRIERS TO ACCESS HEALTHCARE IN AFGHANISTANMSF AFGHANISTAN IN NUMBERS(JANUARY–DECEMBER 2022)
323,231

69,12648,081

14,692

emergency room
admissions

outpatient
consultations

inpatientadmissions

surgicalinterventions

42,704

15,432

9,351

6,429

deliveries assisted, of
which 8,147 were direct
obstetric complications(including complicateddeliveries)

measles patientstreatedchildren admitted
to the Inpatient
Therapeutic Feeding
Centres (ITFCs)

children enrolled
in the Ambulatory
Therapeutic Feeding
Centres (ATFCs)

26,0882,752

consultations for
drug-sensitive
tuberculosis

drug-sensitive tuberculosis patients and 106
drug-resistant tuberculosis patients enrolled ontreatment

12

PERSISTENT BARRIERS TO ACCESS HEALTHCARE IN AFGHANISTANTHE HARDSHIPS OF A PROTRACTEDECONOMIC CRISIS
Despite two decades of development funding in
support of Afghanistan, which provided somepositive outcomes and improvements for a few
sectors, major challenges remained in 2022,
for example in the health sector. The economy
remained in a vulnerable state, heavily dependent
on aid and crippled by weak governance, conflict,insecurity, political instability and lack ofinfrastructure.7 Since the Islamic Emirate of
Afghanistan (IEA) took power in August 2021, theAfghan economy has plunged further. There wasan abrupt halt to foreign aid, which previously
supported most public expenditure for provisionof services, while the US Government froze some
US$7 billion of overseas assets of the AfghanCentral Bank, in addition to more than US$2 billion
held in European banks and in the United ArabEmirates, contributing to a major liquidity crisis.
In September 2022, the US Government released
US$3.5 billion in Afghan assets to be managed bya Swiss trust fund, a measure whose effects inalleviating the crisis have yet to be felt. At this stage,
the economic shocks are reflected in a worsened
humanitarian crisis across the country. Althoughfunding to restore basic services has resumed inrecent months, it remains significantly lower than
before August 2021, when billions of dollars were
pledged8 for development funding (with security
and development grants equaling around US$9

“By 2020, grants had declined to around 45 percent of GDP,but still financed around half of the government budget,
75 percent of total public expenditure, and 90 percent of
security expenditures.” Afghanistan Development Update,
World Bank, April 2022, https://thedocs.worldbank.org/en/
doc/5f01165822f3639224e0d483ba1861fc-0310062022/related/
ADU-2022-Key-Messages.pdf

billion per year).9 Besides not bringing a durable
solution, the funding that is currently available isinsufficient to address existent and growing needs.
These effects are noticeable in the health system,
which struggles to remain afloat. As long as theroot causes of Afghanistan’s economic challenges
remain unaddressed, the sudden withdrawal ofaid can only lead to a worsening of the country’s
humanitarian crisis.10
In addition, pre-existing international sanctions
against designated members of the current
government of Afghanistan are being felt
nationwide. Despite targeting specific people andinstitutions, and despite the series of exemptions
issued and expanded since the last quarter of 2021
to enable and facilitate the transfer and paymentof funds and economic resources necessary forboth humanitarian and development commercial
transactions, donors and various private
businesses and financial institutions remain overly
cautious when it comes to transactions involving
Afghanistan.
The political changes from August 2021 and theconsequent reduction in foreign assistance haveplayed a noticeable role in exacerbating an economic
and banking crisis that directly affects people’s
access to all basic services, including access to afunctioning health system, compounding a crisis
already impacted in recent years by the exit ofskilled workers. Funding for the US$4.4 billion

7

Foreign aid to Afghanistan could reach $12 billion over four years,
some with conditions, November 2020, https://www.reuters.com/
article/uk-afghanistan-diplomacy-aid-idUKKBN2840U7
8

9
Afghanistan Development Update, World Bank,
April 2022, https://thedocs.worldbank.org/en/
doc/5f01165822f3639224e0d483ba1861fc-0310062022/related/
ADU-2022-Key-Messages.pdf

Afghanistan: The Problems with Aid Dependency and the Needfor a Plan B — Annie Wernersson. https://www.ui.se/globalassets/ui.se-eng/publications/ui-publications/2021/ui-brief-no.-6-2021.
pdf

10

13

PERSISTENT BARRIERS TO ACCESS HEALTHCARE IN AFGHANISTAN

humanitarian response requested by the UN, thelargest single-country aid appeal in the history of
the UN, fell short by US$1.4 billion.11

It’s difficult. We are between
fire and water. Before we had
the security problem, but
now we face the economic
problems. It’s more difficult
to access food. The real
problems are the lack of jobs
and food is more expensive.

In the meantime, people’s humanitarian needs
keep soaring. In 2022, an estimated 22.8 million
people, more than half the Afghan population,
were facing food insecurity, and an estimated 24.4
million were in need of humanitarian support, with
18.1 million in need of health assistance, according
to the UN.12 In addition, UNICEF estimated that
3.2 million children in Afghanistan suffered acutemalnutrition in 2022.13 And 2023 begins with OCHA
estimating that this year 28.3 million people willneed humanitarian and protection assistance, withfood insecurity being the main driver of the need. 14

Male MSF staff, Kabul

In general, the situationis very bad in Afghanistan,everything is more expensive.
The major problem isthat people cannot feed
their families, because of
decreased income. In thepast some employers used
to provide meals for theiremployees, now most of them
do not have food anymore.

The chilling effect of the sanctions, combinedwith development funding gaps and frozen assets
overseas, continue to negatively affect the whole
economy, with ordinary Afghans bearing thebrunt.15 The economy has been crushed, leaving
millions of people out of work and struggling tofind employment. Food prices have soared acrossthe country. Those people with jobs are supporting
more family members, many people do not haveenough to eat, and others are delaying seeking
healthcare as they cannot afford it.

Male MoPH staff, Khost

THE BURDEN OF DIRECT AND INDIRECT
MEDICAL COSTS
Financial Tracking Services, OCHA, accessed on 05
January 2023, Special Inspector General for Afghanistan
Reconstruction (SIGAR), April 2022, https://www.sigar.mil/pdf/
quarterlyreports/2022-04-30qr.pdf
11

12

Afghanistan Humanitarian Response Plan 2022

UNICEF Afghanistan Humanitarian Situation Report, 1-28
February 2022, https://reliefweb.int/report/afghanistan/
unicef-afghanistan-humanitarian-situation-report-3-1-28february-2022#:~:text=UNICEF%20estimates%20that%203.2%20
million,signficant%20rise%20in%20measles%20cases.

13

The multi-layered humanitarian crisis in
Afghanistan has developed to the point where
people have multiple medical and humanitarianneeds. These needs are increasing, which isbacked up by the findings of the Afghanistan
Multi-Sector Needs Assessment16 and the
Humanitarian Situation Monitoring by REACH:17

14

Afghanistan Multi-sectoral Needs Assessment, Save theChildren, January 2022, https://resourcecentre.savethechildren.
net/pdf/Afghanistan-MSNA-Full-Report-March2022.pdf/

Strategic Patience: Sustainable Engagement with a Changed
Afghanistan, August 2022, https://quincyinst.org/report/strategicpatience-sustainable-engagement-with-a-changed-afghanistan/

Evolving needs – key trends. Humanitarian Situation
Monitoring, March 2022, https://www.impact-repository.org/
document/reach/498836df/REACH_AFG_Humanitarian-SituationMonitoring-HSM-Key-Findings-Presentation_February-2022-1.
pdf

UNOCHA, December 2022, https://reliefweb.int/report/
afghanistan/afghanistan-humanitarian-needs-and-plannedresponse-2023-endarips

15

14

16

17

PERSISTENT BARRIERS TO ACCESS HEALTHCARE IN AFGHANISTAN

87.5%

of those surveyed by MSF included costs astheir main barrier to access healthcare, anincrease of 18 percent in comparison to the2021 survey. Within these answers, almost 58
percent highlighted direct medical costs as oneof their main barriers, while over 42 percent
mentioned indirect costs such as transport and/or
accommodation.

Afghans have been compelled to adopt negative
coping mechanisms to adjust to their financial
situation.18
Eighty-eight percent of survey
respondents delayed, suspended or decided not
to seek medical care due to reported barriers, anincrease of 14.3 percent in 2021, suggesting thateven though people can travel more freely in 2022,
travelling to seek healthcare is still a challenge
for many. Fifty-two percent of these respondents
believe their relative died due to lack of or delayedaccess to healthcare in the past 12 months.
People’s financial circumstances represent a major
barrier to accessing medical care, while accessing
healthcare itself is an additional economic burden
for many people19 :“36% of HHs reported that they decreased expenditures on
healthcare and education, as a livelihood coping strategy”, Mid-Year
Whole of Afghanistan Assessment, Health Cluster Coordination
Meeting, June 2022

18

“14% of HHs reported ‘healthcare’ as main reason for debt”,
Mid-Year Whole of Afghanistan Assessment, Health Cluster
Coordination Meeting, June 2022

97.5%
of respondents said that they had experienced
financial difficulties due to spending money on
healthcare, as they either had to borrow, dig into
their savings, or sell household items or property.
This represents an increase of 20 percent comparedto MSF’s 2021 survey. These findings are in linewith people’s increasingly poor economic situation
and with the crisis within the health system, where
neither the public health system nor private clinics
can meet people’s existing and growing needs.

I live in Farah and I came tothis hospital [Herat Regional
Hospital] by car. It took us fourhours to get here. My child wassick for seven days. First I went
to a public hospital, then to four
private clinics, but my childwas still sick. One of the private
doctors gave us a prescription
for 1,000 AFG [around 12USD].
Where I live there’s a publicclinic, but they gave us half atablet, they did not give us all
the medication [we needed].
I live with seven people, it’s
not easy to pay for what weneed. We do not have enough.
For us it was difficult to pay
for transport to Herat city andthat’s why we went to private
clinics. Now my child is worse,
and we owe a lot of money.

19

Female caretaker, Herat Regional Hospital15© Nava Jamshidi, 2022

PERSISTENT BARRIERS TO ACCESS HEALTHCARE IN AFGHANISTAN

Edalat sits by his son’s bed in the male inpatient department at the Kunduz Trauma Centre in Afghanistan. His son, Shafiullah, was injured in a
traffic accident in Kunduz City and had to undergo a surgical procedure known as internal fixation.

LOSS OF INCOME, RISING LIVING COSTS
Our survey shows 91.2 percent of respondents
reporting a decrease in their income over the
past year – which is in line with UN World Food
Programme findings from February20 and June
2022.21 This figure is a more than 15 percent increaseon MSF’s 2021 survey. Almost 64 percent of those
who reported decreased incomes indicated that amajor contributing factor was being unemployed
or self-employed/owning a business. Respondents
reported being unable to generate previous levels
of income due to the general deterioration of theeconomy and to people’s decreased spending power.
Almost 30 percent also mentioned high prices asa contributing factor, especially for food items, as
inflation affected all basic items, but salaries and
20
WFP, February 2022: 85% of income-earning households in
Afghanistan reported a significant decrease in income , while
another 21% reported no income earned at all during themonth

Afghanistan Food Security Update, round ten, WFP, June
2022, https://reliefweb.int/report/afghanistan/wfp-afghanistansituation-report-10-june-2022#:~:text=Situation%20
Update&text=A%20total%20of%2018.9%20million,IPC%20
Phase%203%20(Crisis).
21

16

other forms of income did not necessarily increasein line with inflation.22 In Kandahar and Helmand
provinces, farmers made a direct connection
between their decreased income and the droughtin the region, the worst in Afghanistan in 27 years.
Conflict, insecurity and the illness of a family
member were also among reasons cited for adecrease in income.

22”Households may be spending their money on cheaper, lessnutritious or varied foods to cope with the rising prices and fallingincomes of the past 6 months, with implications for possible
worsening of severity of food insecurity and malnutrition without
continued assistance.” Mid-Year Whole of Afghanistan Assessment,
Health Cluster Coordination Meeting, June 2022

PERSISTENT BARRIERS TO ACCESS HEALTHCARE IN AFGHANISTANSOARING MEDICAL AND
HUMANITARIAN NEEDS AND A
STRUGGLING HEALTHCARE SYSTEM
People’s access to healthcare in Afghanistan has
been affected by overlapping shocks that have hit
the country. Conflict and natural disasters canprevent people from reaching basic or lifesaving
medical assistance, but so too can economic andfinancial struggles. This is the case in Afghanistan,where multiple factors have increased people’s
medical needs and made their access to healthcare
even more challenging.

There is no medicine, no goodcheck-up, no treatment inpublic health facilities. We
can’t afford private clinics.
Once, I borrowed some cash
to go to a private clinic. Now
I don’t have money to return
my loan.
Male caretaker, Khost95%
of survey respondents reported facing
difficulties in affording food over the past
12 months. CHALLENGES IN AFFORDING

The main thing we notice hereis the economic situation,
but also displacement. In
general, most people arehaving difficulties affording
food. Our patients and people
from the communities also
tell us they can’t even afford
dry old bread and that they go
to bed hungry.
Male MSF staff, Herat Regional Hospital

FOOD: MALNUTRITION
In 2022, MSF teams treated more than 4,260 patientsfor malnutrition at the Inpatient Therapeutic
Feeding Centre (ITFC) in Boost hospital, Helmand
province, an increase of 33 percent in comparison
to 2021, which was already 44 percent higher than2020. Total admissions to the ITFC in Herat soaredin 2022 and rose by 54 percent, with more than
3,753 patients receiving treatment – half of themunder six months of age. In 2021, admissions were
44 higher than in 2020.

17

PERSISTENT BARRIERS TO ACCESS HEALTHCARE IN AFGHANISTAN

Some have nothing, nofood at all. Food prices are
increasing, even milk is more
expensive. This economiccrisis has affected people who
used to work for the previous
government, but private
businesses have also suffered.
People had to close theirbusinesses and a lot of people
lost their jobs.‍

It’s difficult to buy foodfor everyone in the family.
Sometimes we don’t haveanything to cook. I eat, butsometimes, because the foodis not enough, I give it to mychildren first. We also do nothave enough water and wehave to bring it from far away.
Female caretaker, mother of 10, Kandahar

Male MSF staff, Herat Regional Hospital

The rise in malnutrition is likely the result of
a combination of factors: a broken economy;
climate shocks, such as drought and floods; andinsufficient availability of medical assistance forhealth conditions that can cause or exacerbate
malnutrition (e.g. acute diarrhoea and measles).
The general impact of malnutrition is also reported
to disproportionately affect women,23 and in some
MSF-supported facilities, such as in Kandahar,
in 2022 girls accounted for around 55 percent ofadmissions to both the outpatient therapeutic
feeding programme and the ITFC, with mortality
almost 90 percent higher for girls than for boys in
the ITFC. Some accounts suggest that when there
is not enough food for everyone in a household,women and girls may be deprioritised and thisdoes tend to be the case in countries where genderinequalities are institutionalised – especially whencombined with poverty.24 However, what seems
very concerning in Afghanistan is that the healthseeking behaviour may also change according to
the gender of the child; that a family may seek carefaster for a boychild than a girl.

23”Economic and Food Crisis in Afghanistan: The Impacts on
Women and Girls“, August 2022, https://www.care-international.
org/sites/default/files/2022-08/Afghanistan%20Food%20
Security%20Report_advocacy%20brief_August%202022.pdf
24“Food discrimination against women in Afghanistan”, https://reliefweb.int/report/afghanistan/food-discrimination-againstwomen-afghanistan

18

The economic crisis has
impacted a lot our society.
Some mothers who come toour hospitals are struggling
to afford food for themselves.
How can they produce
milk to feed their children?
Sometimes we see mothers
putting tea in the bottle togive to newborn babies of only
seven or eight days; this isdangerous for the baby.
Female MSF staff, Khadhestan clinic, Herat

Possibly related to the above points, MSF teams havealso witnessed malnutrition in adults, indicating
an increased need for nutritional support to entire
families rather than only focused on children.
Of 6,670 pregnant or lactating women screenedusing MUAC (mid-upper arm circumference)25 at
MSF’s Kadhestan clinic and Shaidayee settlementin Herat province in 2022, nearly 16 percent had
moderate acute malnutrition (MAM). This is almost
double the proportion of moderately malnourished
25
Mid Upper Arm Circumference protocol to detectmalnutritionPERSISTENT BARRIERS TO ACCESS HEALTHCARE IN AFGHANISTAN

women seen in 2021, despite MSF having received
32 percent fewer pregnant and lactating womenpatients in 2022. In Khost, MSF started screening
pregnant and lactating women for malnutrition in
2022; of the 16,328 women who were screened, 15
percent had MAM and 0.5 percent (91 women) had
severe acute malnutrition (SAM). In Boost hospitalin Helmand province, MSF screened more than
17,344 pregnant and lactating women in 2022, ofwhom eight percent had MAM. This represented anincrease of 76 percent in MAM pregnant lactating
women in comparison to 2021, while the number ofscreened patients increased by 56.7 percent. When
pregnant or lactating women are malnourished,
this represents a higher risk for themselves and fortheir children as it is a potential cause of prematurebirths.
PREVENTIVE CARE THROUGH THE LENS OF
MEASLESAs the humanitarian crisis worsens, so does thepreventive care available. The measles outbreakof 2022 brought to light people’s limited accessto immunisation services across Afghanistan, in acontext where malnutrition – a complicating liferisk factor for measles – is a significant issue. In
2022 MSF expanded its activities for measles care,treating more than 15,400 patients in four locations(most of them in Helmand and Herat). In Helmand
province, where MSF regularly treated measles inprevious years, our teams received 5,657 patientsin 2022, a decrease of around seven percent from2021, but a staggering 289 percent increase on 2020
figures. This steep increase could be attributed topeople being unable to seek care at the height of
the COVID-19 pandemic in 2020, but it still reveals
the increased and urgent need for improvements
to vaccination programmes. It should be noted thata few countrywide mass vaccination campaigns
in 2022, run by the MoPH and supported by theWorld Health Organisation (WHO), were probably
an important contributing factor to a decrease inadmissions of measles patients in the final monthsof 2022, not disregarding the fact that numbersof measles cases are usually lower in the second
half of the year. However, better access to a proper

system for routine vaccinations, with improved
coverage in place to reduce future outbreaks, isstill of the utmost importance to prevent this cyclefrom repeating in the coming years.
Afghanistan’s
healthcare
systemremains
dependent on the additional support of externalorganisations and continues to struggle in both the
mitigation and the response to disease outbreaks,
exposing the population to severe health risks, whilepeople’s access to preventive healthcare, including
vaccination programmes, remains insufficient.
THE EFFECT OF LIMITED ACCESS TOHEALTHCARE ON MATERNAL AND NEONATALHEALTH
Afghanistan has one of the highest maternalmortality rates in the world, with 638 deaths forevery 100,000 live births in 201726 (the most recent
year for which data is available). With the economiccrisis as well as people’s access to health services
deteriorating, it is hard to be optimistic about
the future. Afghanistan is still one of the mostdangerous places in the world to be a woman andto become a mother.27 According to the United
Nations Population Fund (UNFPA), this is due to a
combination of poverty, lack of access to healthcare
and gender inequality. 28
Although not necessarily linked to the lack of
medical assistance, or delays in reaching it,

26
638 per 100,000 live births, data from 2017, ”Maternity Mortality
Ratio”, WHO, 2019, https://data.worldbank.org/indicator/SH.STA.
MMRT?locations=AF
27“Afghanistan: the worst place to be a mother”, July 2011,https://unama.unmissions.org/afghanistan-worst-place-bemother; ”Afghanistan Country Profile”, UNICEF, page accessedin October 2022, https://data.unicef.org/country/afg/; ”Maternity
Mortality Ratio”, WHO 2019, https://data.worldbank.org/indicator/
SH.STA.MMRT?locations=AF ; ”Afghanistan has one of thehighest maternal mortality rates. Health crisis is worsening”,
May 2022, https://www.intersos.org/en/afghanistan-has-oneof-the-highest-maternal-mortality-rates-health-crisis-isworsening/#:~:text=In%202002%2C%20Afghanistan%20had%20
the,638%20deaths%20per%20100%2C000%20births
28“Midwives on the front lines working to reverse Afghanistan’shigh maternal death rate”, October 2020, https://www.unfpa.org/
news/midwives-front-lines-working-reverse-afghanistans-highmaternal-death-rate

19complicated obstetric cases (including deliveries
with complications) increase the maternal andneonatal life risk. In Boost hospital in Helmand
province in 2022 MSF teams assisted 22,948
deliveries, 21.5 percent more than in 2021. Direct
obstetric complications (including complicateddeliveries) accounted for 21 percent of the total
deliveries in 2022, affecting 95 percent morepatients than in the previous year. In Khost
maternity hospital, MSF teams assisted 19,756
deliveries in 2022, 4.5 percent more than in 2021.
In Khost, complicated cases represented almost
17 percent of total deliveries in 2022, and anincrease of 17.4 percent on the number of patientsin comparison to the previous year. This increaseis probably linked to MSF programme design inthe province, with increased efforts being made topromote the referral of complicated cases to MSF’s
maternity hospital in Khost. These two projects are
in different regions of the country, with different
experiences of the socio-economic shocks hitting
Afghanistan, yet the picture is similar. MSF data fromcomprehensive emergency obstetric and neonatal
care facilities shows that access to maternal andneonatal lifesaving care remains core to maternaland child health. Skilled emergency obstetric carein Afghanistan is limited, as MSF has witnessed invarious districts of Khost, Helmand and elsewhere.
This means that women patients must travel long
distances to reach skilled care, in addition tocontending with social policies that restrict the
movement of women. Both these factors are likely
to contribute to delays in reaching medical careand increased maternal deaths. A consequenceof these barriers is that women are increasingly
opting to give birth at home, with all its attendantrisks – something MSF has been noticing more
and more. The need for improved access to skilled
emergency maternal and neonatal care surfaces
every time MSF meets with community members,
elders and provincial authorities. Whatever thelocation in Afghanistan, communities always ask
MSF to implement more maternity projects.
The overall increase in the numbers of women
giving birth in MSF facilities brings with it anincrease in complicated deliveries and neonatal
unit admissions, but there are other factors that20

© Oriane Zerah/MSF, 2022

PERSISTENT BARRIERS TO ACCESS HEALTHCARE IN AFGHANISTAN

Bibi Amina, who is three years old, suffers from tuberculosis andanaemia. She was brought to the MSF-supported Boost hospital in
Lashkar Gah, Helmand province by her father Abdullah.

continue to negatively affect women’s health,leading to avoidable negative health outcomes,
including for newborn babies. Among the main
factors are a lack of access, and delayed access,to quality antenatal care. Timely antenatal carecan help mitigate complications – and therefore
prevent deaths – of both women and their babies.
However, for most women, seeking timely
antenatal care is not an option, due to various
barriers: a lack of available services; shortagesof trained and qualified staff (especially women
healthcare workers) in district health facilities;
and travel restrictions or difficulties travelling long
distances, compounded by economic barriers thatmake journeys to hospital unaffordable and paying
for healthcare impossible for many women.
The long-standing socio-cultural practice known
as the mahram requires that women leaving home
are accompanied by a male relative as a guardianor chaperone. This practice is reportedly being

PERSISTENT BARRIERS TO ACCESS HEALTHCARE IN AFGHANISTAN

enforced more strictly by authorities and canpresent an obstacle to women accessing essential
services, including healthcare for themselves andother family members, and makes it even harderfor the healthcare system to meet their needs. The“mahram requirement” can affect a woman’s ability
to reach a hospital – whether as patient, caretakeror humanitarian/health worker – in several ways,
for example when no male relative is available toaccompany her, or when a journey which is alreadyhard to afford for one person becomes unaffordable
when paying for two.

We are not near the healthfacility and we cannot travela long way without male
relatives.
Female caretaker, Kandahar

Other factors that put the lives of women and theirbabies at risk beyond delayed healthcare include
reduced access to food; short intervals between
pregnancies; and the misuse of labour-inducing
drugs, taken at home or before seeking specialistcare. Such drugs are reportedly readily available
on the market and easily accessible without aprescription.
INCREASED PATIENT NUMBERS DO NOT EQUATEWITH TIMELY ACCESS TO QUALITY HEALTHCARE
The reported reduction in conflict and people’s
increased ability to move around in 2022 comparedwith previous years did not appear to sufficiently
improve people’s ability to reach healthcare.
Access continued to be impeded by factors such as
the economic crisis and unavailability of services.29
Throughout 2022, both MSF-run and supported

facilities had a high bed occupancy rate. Many ofthe patients and caretakers at these facilities cited
difficulties in accessing quality medical care atother facilities closer to home and dissatisfaction
and lack of trust in the healthcare system generally
as reasons for coming to those facilities where MSF
worked. In 2022, bed occupancy rates remained on
average at 150 percent in Boost’s ITFC, and 117
percent in MSF’s ITFC in Herat Regional Hospitaland at more than 117 percent in the inpatient
departments of Boost hospital.
In Boost hospital in Helmand, the Emergency
Department (ER), saw a 51 percent increase inpatients compared to 2021. Approximately 43.5
percent travelled to the city from outside the urban
district of Lashkar Gah. Needing to travel long
distances to seek emergency medical care, or
being unable to afford to travel, caused worrying
delays to receiving timely healthcare. For example,
in comparison to 2021, the ER in Boost hospital saw
an increase of 69 percent of patients coming from
Baghran district, travelling at least 160km to reachthe MSF-supported hospital. This overall increasein patients could be attributed to several factors,
including reduced conflict, fewer roadblocks, a lackof fully functioning health facilities, inadequate
medical supplies, and shortages of healthcare staff
in the rural areas.
Compared with 2021, in 2022 at Herat Regional
Hospital, there was a 70 percent increase of ITFC
patients travelling from Farah province (around280km away) and a 38 percent increase of patientscoming from Badghis province (around 150km
away). People travelling long distances like theseto seek medical care is particularly concerning
within the context of an economic crisis that makes
it difficult for many people to afford transportation
costs. If affordable healthcare was available closer
to home, people would not have to overcome suchfinancial obstacles to access much needed medical
care.

29
”Barriers to health have mostly remained similar to 2021 but
have intensified. E.g., unavailability of medicines from 24% in 2021
to 37% in 2022. Same for the financial barrier” Mid-Year Whole ofAfghanistan Assessment, https://www.humanitarianresponse.info/
sites/www.humanitarianresponse.info/files/documents/files/midyear_2022_key_findings_presentation_mid-year_woaa.pdf

21

In terms of healthcare, mostof the good doctors left thecountry. We feel that evenprivate healthcare is worse. We
heard from one clinic that sinceAugust [2021] it’s been moredifficult to keep the quality ofcare, mostly because of a lackof qualified staff, medications
and equipment maintenance.
The main problem of public
hospitals is that there are
too many people, [they’re]
too crowded, [there are]not enough qualified healthworkers, a lack of quality
services; and they also don’t
have medical items or supplies
nor medications.
Male MSF staff, Kabul[A] private doctor is thehighest cost for us – I didn’t
have enough money to bring
my child to the private clinic.
We went to the public healthfacility in Wayan, and they did
not give us any medicationor food and they referred us
to MSF. I paid the costs of the
1.5-hours [of] travel with somesavings.
Male caretaker, Kandahar

22© Tom Casey/MSF, 2022

PERSISTENT BARRIERS TO ACCESS HEALTHCARE IN AFGHANISTAN

Samira, who suffers from measles, is being treated at the
MSF-supported Boost hospital in Lashkar Gah, Helmand province.

More than one third of survey respondents who
visited the health facility nearest to their housewere not satisfied with the services. The mostcommon reasons cited were lack of medications,being asked to pay high amounts for medication,and being asked to buy the medication privately.
People also expressed a lack of trust in the qualityof services provided to patients and caretakers,
and they perceived public hospital staff as lacking
experience and professionalism. People who livein the districts and rural areas, far away fromthe centre of the provinces, are often left with noother option but to undertake a long and expensive
journey to find free, quality medical care. But many
people cannot afford to pay the transportation
costs, and are forced to borrow money, which is anadditional burden for those already suffering fromlack of healthcare.
These experiences and perceptions are not new.30
A UNICEF’s analysis of the Sehatmandi Project 31
conducted between January and May 2022 found30
In the 2021 MSF report, among the surveyed patients andcaretakers who had visited a public medical facility in the lastyear, 45 percent said they were not satisfied with the services
provided
31
The System Enhancing for Health Actions in Transition (SEHAT)
Program aims at financing the implementation of the Basic
Package of Health Services and the Essential Package of HospitalServes, https://www.moph.gov.af/en/sehatmandi-projectPERSISTENT BARRIERS TO ACCESS HEALTHCARE IN AFGHANISTAN

Many people tell us they came to MSF and not to another health facility
near their home because the other places don’t offer [the] same
services, quality of staff or free medications. Public hospitals are
becoming worse. People still go to Herat Regional Hospital because
they can’t afford the consultations in private clinics. When some of
my relatives are sick, I take them to a private clinic, I don’t think [the]quality is good at MoPH.

that just nine percent of health facilities reported
having a functional operating theatre, 28 percent
had a functional laboratory, 45 percent had an
Emergency Room, and 27 percent reported being
open at night.32 According to the Mid-Year Wholeof Afghanistan Assessment conducted by the InterCluster in 2022, nearly half of the respondents
considered that medicines and equipment weregenerally not available in the health centres in theirareas.33 Reports of “No functional health facility
nearby” increased from 19 percent in 2021 to 29
percent in 2022. 34© Nava Jamshidi, 2022

Male MSF staff, Herat

Hadia is being moved to surgery in the MSF Kunduz Trauma Centre in
Afghanistan after she was injured by shrapnel. The accident happened
while she was playing near her home in Kunduz City. Unexploded
ordinance still pose a major threat to people of Afghanistan.

32
Presented at the health cluster meeting in Afghanistan on the
7th June 2022.
33
Mid-Year Whole of Afghanistan Assessment, Health Cluster
Coordination Meeting, June 2022

Whole of Afghanistan Assessment, September 2022, file:///C:/
Users/MSFuser/Downloads/REACH_AFG_WoA-2022_KeyFindings_Presentation_Published-2.pdf
34

23

PERSISTENT BARRIERS TO ACCESS HEALTHCARE IN AFGHANISTANTHE PROTRACTED STRUGGLE OF AN
UNDER-RESOURCED HEALTHCARESYSTEM COMPOUNDED BY FURTHER
CHALLENGES
Afghanistan’s public healthcare system has been
under-funded, under-resourced, over-burdened
and under-performing35 for years, despite billionsof dollars being invested by donors. Until 15
August 2021, the World Bank’s Sehatmandi Project
supported approximately two-thirds of all public
facilities in 31 of Afghanistan’s 34 provinces. The
remaining facilities were directly managed by
the Afghan MoPH. In August 2021, the overnightsuspension of development funds and financialtransactions that were vital to public service
provision brought the entire public health sector
to the edge of collapse. Doctors, nurses andother healthcare workers stopped receiving theirsalaries. This came after many had already not
been paid for months due to a mix of under-funding
and mismanagement, including the misuse offunds. Across the country, clinics and hospitals
either closed or ceased to be functional in a matterof weeks. The facilities that were able to stay open
faced acute shortages of essential medicines andsupplies and struggled to provide care. Between
September and December 2021, the UN stepped
in to finance the Sehatmandi Project. In December,donors decided to redirect US$100 million fromthe Afghanistan Reconstruction Fund (ARTF) to
UNICEF to support the next phase of Sehatmandi
in partnership with the World Health Organisation.36
Only 17% of Sehatmandi were functional in September 2021,
according to WHO, https://www.who.int/news/item/22-09-2021acute-health-needs-in-afghanistan-must-be-urgently-addressedand-health-gains-protected3536Donors back $280 million transfer for Afghan food, health,
December 2021 https://www.reuters.com/world/asiapacific/exclusive-donors-expected-back-280-mln-transferafghanistan-2021-12-10/

24

In June 2022, UNICEF, the World Health Organisationand the World Bank agreed on US$333 million
to fund the Health Emergency Response (HER)
project. The project aims “to deliver basic health,nutrition and COVID-19 services in partnershipwith national and international service providers,in more than 2,300 health facilities nationwide”
and is supposed to have new contracts startingin February 2023, after contracts with several old
implementing partners were extended during 2022.
37
At this stage, however, funding is only ensured forthis project until December 2023.
Since August 2021, additional resources and funds
have been provided by donors and humanitarianorganisations including MSF, the International
Committee of the Red Cross (ICRC), UN agencies
and others. These organisations stepped up
their support to the health system, especially forsecondary healthcare across the country, but major
funding gaps and uncertainties remain. Several
specialised and teaching hospitals still lack support
or are fully dependent on short-term bilateralagreements with international organisations tocover staff salaries, medicines, supplies and otheroperational costs. Additionally, there are no longterm solutions and a lack of investment in multiyear strategies to support the healthcare system.
Despite reported improvements, there havebeen long-standing concerns for years over the37
UN Portal, Provision of Primary and Secondary Healthcare in
All 34 Provinces of Afghanistan, December 2022, file:///C:/Users/
MSFuser/Downloads/Provision%20of%20Primary%20and%20
Secondary%20Healthcare%20in%20All%2034%20Provinces%20
of%20Afghanistan.pdf

PERSISTENT BARRIERS TO ACCESS HEALTHCARE IN AFGHANISTAN

management of healthcare funds, including
concerns about performance reviews, andverifications and monitoring that remain achallenge due to the World Bank’s remote supportmodel.38 MSF has provided substantial support to
Basic Package of Health Services (BPHS) facilities
in addition to expanding the programme’s capacity
in order to ensure that access to these facilities
remains uninterrupted. This illustrates the flawsof the grant award temporary contracting system.
In essence, organisations have become de facto
substitutes for a functioning public healthcare
system, but this is not sustainable. International
actors often remain in the country without a clear
exit strategy, and design a healthcare system
without meaningful involvement or input fromAfghan health authorities. Which is not a workablelong-term approach and nor does it foster
ownership.
One of the main challenges with the Sehatmandi
Project is that the Basic and Essential Healthcare
Package (BPHS/EPHS) implementers often don’t
have the resources and supplies necessary todeliver adequate services. This is largely due to thefinancing model of the healthcare system, which
does not allow for meaningful long-term strategies
and the needed investments in infrastructure,equipment and trainings. In addition, it ischallenging to recruit skilled healthcare workers,
especially women, in part but not only due to many
people leaving the country in recent years.
SHORTAGE OF WOMEN HEALTHCARE WORKERSIMPACTS AVAILABILITY OF HEALTHCARE
The majority of MSF’s medical teams in
Afghanistan are women. They make up more than
51 percent of our medical staff, nearly 900 doctors,
nurses and other professionals. Women staff areespecially important for our maternal healthcare
programmes, as maternity units are largely
women-only spaces. And many of the workers insome paediatric departments and therapeutic
feeding centres are women, for example in MSF’s
project in the Herat Regional Hospital. However
it is increasingly challenging to recruit qualified
women health workers and this is something MSF
has struggled with since 2014.
As we have seen earlier in this report, the needs are
increasing and many more women Afghan medical
staff will need to be trained to ensure access to
medical services for women. For this to happen,
women need to have access to education and beallowed to work. The December 2022 restrictions
run counter to this. The government of Afghanistan
putting in place restrictions banning women from
attending university – on top of the 2021 closureof secondary schools to girls – and from working
for international and national non-governments
organisations will mean a considerable reductionof opportunities for women.

Women and girls are facing
problems, because in ourvillage, under our culture
and traditions, people are
not ready to allow theirfemale family members andgirls [to] be treated by male
doctors. And here, we don’t
have female doctors … more
medicine and equipment
should be provided for thehealth facilities and moreexperienced doctors should
be appointed in the clinics.
Female caretaker from Safiam, Boosthospital, Helmand

38
Donors’ Dilemma: How to provide aid to a country whose
government you do not recognise, July 2022, https://www.
afghanistan-analysts.org/en/reports/international-engagement/
donors-dilemma-how-to-provide-aid-to-a-country-whosegovernment-you-do-not-recognise/

25

PERSISTENT BARRIERS TO ACCESS HEALTHCARE IN AFGHANISTAN

Afghanistan already has a shortage of qualified
women healthcare professionals, and there
is a long-standing and socio-cultural lack ofacceptance of males as healthcare providers for
women.

Doctors should be female. If
doctors are male we have to
speak about our problems fromunder [the] burqa. Then, they
can’t diagnose [a] disease well,like a sore throat.
Female patient, Herat Regional Hospital

And the barriers they face and challenges they
have to overcome, as well as the consequences,
impact not only the women themselves but also
their families and Afghan society as a whole.

Women suffer from some
restrictions ... After facing
challenges to leave the house,
they don’t always find female
doctors available. And even in
my private car, I was stopped
and my wife was obliged to
sit in the back alone. This
happened to us recently.
Male MSF staff, Kabul

Women’s mobility has indeed become more
restricted, particularly in more conservative
areas including some of the provinces where MSF
conducted these interviews: Kandahar, Khost andHelmand. But, in Kabul, some MSF staff reported
that women traveling alone without a mahram inshared taxis are sometimes requested to sit in theback seat of the car and cover the cost of all threeseats as no-one else is allowed to share the taxi
with them. This adds an additional financial burden
and can make a woman’s trip to a healthcare

26

facility twice or even three times more expensive
than a man’s. This impacts women’s ability toreach a hospital, workplace, or any other locationand is something MSF reported in 201439 but thathas since worsened in 2022. 40
Working in seven provinces around the country
has also allowed MSF to see that applicationof directives varies, and this leaves room for thewhims of individuals and creates uncertainties forthe women themselves, their families and even
their employer on what is permitted or not.41
ADDITIONAL CHALLENGES
62.5 percent of the surveyed respondents believe
women face worse obstacles when trying to accesshealthcare in comparison to men (more than one
third of these respondents were men).

Some women and girls are notallowed to go out, even if they
are sick. But when their illness
gets serious, their men hurry
to take them to a health post.
Female caretaker, Boost Hospital, Helmand

Moreover, qualitative interviews with male andfemale MSF staff revealed a strong consensus thatwomen faced additional challenges in Afghanistan,mostly in terms of movement restrictions outsideof their houses affecting their access to work or
healthcare for themselves, their children or otherhousehold-members.

39“Between Rhetoric and Reality. The Ongoing Struggle to Access
Healthcare in Afghanistan”, MSF, February 2014.
40“What’s the Status of Healthcare for Women in Afghanistan
Under the Taliban?”, August 2022, https://www.pbs.org/wgbh/
frontline/article/healthcare-women-afghanistan-under-taliban/;and Mid-Year Whole of Afghanistan Assessment 2022, Inter-cluster
and Health cluster Afghanistan, June 2022.
41”Female Participation in the Humanitarian Response in
Afghanistan“, September 2022, https://reliefweb.int/report/
afghanistan/female-participation-humanitarian-actionafghanistan-september-2022-endarips

Dr Lia, a paediatrician, examines a baby in the neonatal intensive care unit (NICU) at Boost hospital, Helmand's
primary provincial hospital in the capital Lashkar Gah.

I think females have less access to healthcare especially because theyneed permission from male relatives. Females have less value in oursociety, less rights. Once a mother told us she would sell her child, she
asked ‘what will I do with a girl?’. The boys grow and work … Before thisregime, we had hopes. Now, we are losing all our hopes. But I want tobelieve it will improve at least for women and that my daughter will beable to go to school. Sometimes I pray that my next child will be a boy.
Female MSF staff, Kabul

27© Andrew Quilty, 2020

PERSISTENT BARRIERS TO ACCESS HEALTHCARE IN AFGHANISTANPERSISTENT BARRIERS TO ACCESS HEALTHCARE IN AFGHANISTANCONCLUSION
In 2022, Afghans struggled to access quality andtimely healthcare due to widespread poverty anda weakened public health system that remained
unable to cope with the growing health needs.
And we have seen access to quality healthcare
becoming even more challenging for women. The
cost of medical care, the cost of transport, the lackof quality healthcare near people’s homes, andconflict have all been major obstacles for years.
On top of these ongoing barriers, Afghans havealso been impacted by the effects of a staggering
economic crisis.
The healthcare delivery model in Afghanistan was
already dysfunctional and has suffered further
in recent years from the effects of insufficientinvestment, inappropriate allocation of funds andshort-term contracts. All of which blocked theway for much-needed long-term strategies andcoherent planning. Between 2021 and 2022 though
the situation has become much worse, and barely
remained afloat due to insufficient or inadequate
funding. The solutions that have been found aretemporary ones and are not sustainable long term.
In its current state, the health system is unable
to meet the growing medical needs of the Afghan
people.
The general perception of improved security has
enabled people to move around more easily than in
the past. MSF has seen an increase in the numberof people coming to its health facilities for careand in some facilities bed occupancy rates are well
above 100 percent. But the high influx of patients
does not mean they have reached medical carewithout challenges and MSF often sees people
arrive after their illness has become a medical
emergency because they have had to contend withtraveling long distances or weighing up whether tospend the money or not to make the journey.

28

RECOMMENDATIONS:To all stakeholders, international donors, aid anddevelopment providers:
The economic crisis needs to be urgently
addressed. International actors must ensure
clear communications and support to thebanking system, aiming for solutions to alleviate
the liquidity crisis, including in terms of thefrozen Afghan assets abroad.
• Sanction exemptions for humanitarian assistanceand development-related transactions should
be clarified to private and public banks in
Afghanistan. Financial transactions would not
only facilitate the roll-out of humanitarian anddevelopment assistance, but also inject cash
into the country.
• Organisations cannot remain as the de facto
substitutes for the public health sector. Whileinternational organisations may have averted
the collapse of the healthcare system, this is
not a sustainable role for them to play. And the
MoPH needs to be involved in identifying andworking through the implementation of longterm solutions for the Afghan healthcare system.

•

To international donors and UN agencies:•••

Increased and sustained funding is essential sothat the Afghan healthcare system can benefit
from sufficient and long-term planning. Durable
solutions for existing medical needs should beprioritised.
It’s urgent and of utmost importance to provide
affordable and accessible healthcare to thepeople of Afghanistan and improve the abilityof the healthcare system to both respond to
emergencies and be capable of meeting theimmediate medical needs of the population.
Significant and urgent investment is needed
to strength service delivery and improve theinfrastructure of health facilities, especially at
the primary level and in the districts. Donors andPERSISTENT BARRIERS TO ACCESS HEALTHCARE IN AFGHANISTAN

authorities should invest in technical support andregular monitoring of programmes and services,
as well as being increasingly accountable for theoutcomes and/or deficiencies.
To the Islamic Emirate of Afghanistan:
The authorities should refrain from imposing
restrictions that impede or delay people’s accessto healthcare, or humanitarian and development
aid. And continue to allow and facilitate timely
and dignified access to healthcare, without
conditionality.

© Tom Casey/MSF, 2021•

Women should be allowed to work in all areasof Afghan life. Women staff play a critical role in
the provision of aid, including medical aid, andno organisation can assist local communities
without them.
• Education should be available for everyone. it isvital in helping to ensure for example that there
are enough skilled workers such as women
medical staff.
• The authorities must ensure the proper allocationof funds for the health sector.
•

Wais Mohammad, MSF anaesthetist, carries out a check on Esa, 63, prior to surgery to remove a kidney stone, Boost hospital,
Lashkar Gah, Helmand Province, Afghanistan.

29© Oriane Zerah, 2022

Patients listen to a morning briefing in MSF’s male inpatient department in the Kunduz Trauma Centre, Afghanistan.
Shir Ali (in the forefront), nicknamed “Lion,” was admitted to the hospital after being injured in a traffic accident in
Kunduz City. The inpatient department in Kunduz has 54 beds and the average bed occupancy rate is 75%.