Afghanistan’s Healthcare Crisis

In the freezing chill of December, Najib spent two days waiting on the main road near his village in the Pato district of Afghanistan’s central Daikundi province.

His wife Sakina (not her real name), expecting twin boys, had experienced an amniotic sac rupture four days before. As a father of six daughters, nothing was more pressing for Najib than ensuring the healthy birth of his sons.

On the third day, he was finally able to flag down a vehicle carrying healthcare workers. The team urged him to take his wife to the provincial capital Nili for treatment, and that evening Najib managed to hire a minivan for 35,000 Afghani (400 US dollars) to take them. It took eight hours for the vehicle to reach their village, and another eight to return to Nili, where they went straight to the provincial hospital.

“Childbirth can be a death sentence.”

But it was too late to save the twins. One baby was already dead, and the other survived for less than an hour after birth.

Blaming Sakina for their deaths, Najib threatened to marry another woman who would be able to give him a son.

When Sakina finally returned home, she told her friend Zahra, “I’m neither dead nor alive.”

“No one but me had bothered to listen to her heartache and sorrow,” Zahra continued, adding that Najib remained angry.

“He found it hard to acknowledge that societal norms, government inefficiencies and challenging geography contributed to his infants’ death. Instead, he kept blaming his wife for their misfortune.”

Sakina’s story is a stark example of the grave consequences of Afghanistan’s ongoing health crisis. With medical services long suffering the effects of decades of war and disruption, the situation has further deteriorated since the 2021 Taleban takeover.

Khoshal Nabizada, the former head of the public health department in Kabul province, attributed this to the mass migration of healthcare professionals, decline in aid, absence of policymaking and management institutions as well as an escalating demand for services.

According to The World Factbook, Afghanistan’s death rate per 1,000 individuals in 2023 is estimated at 12.08, a huge rise from the 2021 figure of 8.79 per 1,000.

Warning that Afghanistan's health system was on the verge of an irreversible breakdown, Nabizada described the current condition simply as "dire".

Last year, the Taleban administration drastically cut the health ministry's budget from around 30.1 billion Afghanis (344 million dollars) in 2021, to 4.5 billion Afghanis (49 million dollars.

Even so, only 16 per cent of development funds and 14 per cent of the regular budget were spent, demosntrating a failing health system that could not utilize its own vastly reduced budget.

“Those who continue to work face terrible risks.”

Before the Taleban took power, international aid accounted for 75 per cent of public expenditure, including healthcare. This assistance was halted after the takeover. The United Nations Office for the Coordination of Humanitarian Affairs (OCHA) reported that the number of people requiring humanitarian aid in 2023 had spiked by 350 per cent compared to 2019. In 2022, 6.6 million people in Afghanistan faced food shortages, up from 4.2 million in 2021.

Compared to 2019, poverty has tripled, and half of all Afghans can no longer afford medicine or treatment. Given the Taleban’s harsh gender ideology, women have been particularly severely impacted.

Sweeping restrictions include limiting access to healthcare. In November 2021, the Taleban prohibited women from entering medical centres without a so-called "legitimate guardian.”

This had to be a man, with it declared to be "immoral" and "illegitimate" for a sick woman to be accompanied by a female relative. Officials also banned doctors from examining or treating these women.

In addition, services related to pregnancy prevention and the accessibility of contraceptive pills were outlawed.

These stringent measures have further hindered women's access to healthcare in a country that has long had an alarmingly high rate of infant and maternal deaths.

In April, the WHO reported that 167 infants and 21 mothers die daily in Afghanistan. According to the United Nations Population Fund (UNFPA), the mortality rate for children under five was 58 per 1,000 in 2021. The CIA World Factbook predicts this will rise to 103 children per 1,000 births by 2023, making it the highest rate globally.

Afghanistan also has the worst maternal mortality rate in Asia. A report from the World Health Organisation (WHO), the United Nations International Children’s Emergency Fund (UNICEF), UNFPA) and the World Bank revealed that 620 out of every 100,000 mothers in Afghanistan died in 2020, costing the lives of 8,698 women that year - a rate more than double the global average. Doctors believe that actual mortality statistics are significantly higher than reported.

Shortly after the Taleban took control, the UNFPA warned that by 2025 Afghanistan could see an additional 51,000 maternal deaths, averaging 12,750 deaths annually.

UNFPA Executive Director Natalia Kanem issued a statement on the first anniversary of the Taleban’s return to power that for women in isolated areas of the country “childbirth can, in effect, be a death sentence”.

Access Reduced

In the wake of the Taleban’s resurgence, around 2,000 health centres established by international organisations closed down.

According to Taleban government data, there were 3,472 active healthcare facilities in the country up to the third quarter of 2022.

These included 725 hospitals (207 public and 518 private) as well as 1,075 primary health centres. The country’s healthcare facilities had a total of 15,318 beds.

According to this official data, this marked a rise from the same period in 2021, when there were 697 hospitals (193 public and 504 private) and 1,003 primary health centres, offering 14,131 beds.

However, public access to these resources has been reduced. In 2020, there was one public health centre for every 11,250 people. By 2022, the ratio dropped to one for every 11,600 people.

There is also a desperate need for essential resources. With local clinics lacking critical equipment, patients are routinely referred to Kabul for diagnostic procedures including CT scans, sonographies and MRIs. Doctors report that medicine shortages frequently left them no choice but to prescribe simple painkillers to most patients.

According to WHO 2021 data, for every 10,000 people in Afghanistan, there were only 2.8 doctors, nurses, and midwives. A severe shortage is defined as 23 doctors, nurses, and midwives per 10,000 people.

Women, again, face particular challenges. The Afghan Statistics Office, under the control of the Taleban, stated that in 2021, 3,535 midwives were employed in Afghan health centres. According to WHO data. the figure was 2,984.

Those who continue to work know they face terrible risks.

Najmeh (not her real name), a midwife in the Chenartu district of Uruzgan, noted that last November, a female Hazara doctor was killed by militants in the province’s village of Chakeh Joi.

"We have no guarantees here," she said. "Our lives could end any moment, but the women here need us. We need to stay in this remote corner of the world."

She recalled an incident in March 2023 when two Taleban militants knocked on the door of Najmeh's busy clinic as she was treating patients.

The men ordered Najmeh to gather her medical supplies and accompany them to their commander's house.

Najmeh realised that if she had refused to go, the men could have forced her at gunpoint and shut down the health centre for several days.

She said, "Legally, we're not supposed to visit patients at their homes, but threats and our moral duty towards women and mothers compel us to go."

Once at the Taleban base, the commander warned Najmeh to ensure the safety of his wife and child. The woman was writhing in agony, having started contractions late the previous night. She did not dare wake her husband and bore the pain until dawn, crying silently and biting her arms to distract herself. When morning came, her husband chose not to take her to the health centre, instead sending his men to bring Najmeh. According to Najmeh, women's health issues are not considered serious in most of this district.

As the pain became unbearable, the other women in the house stuffed a cloth in her mouth, arguing that the men outside should not hear her screams.

With Najmeh's assistance, she gave birth after about half an hour.

The midwife said that this was the third time the commander's wife had given birth, and had never received any healthcare advice during any of her pregnancies.

Healthcare Impact

Numerous life-threatening diseases are going undiagnosed and untreated amidst the crisis, with resources rarely available outside major cities.

According to 2021 Taleban data, only around a third of doctors working in state facilities were specialists, most located in Kabul where only 16 per cent of the population resides.

Cancer carries a high death toll, with only three hospitals offering treatment in Kabul, Balkh, and Herat. The Jumhoriyat Hospital in Kabul is the best equipped, providing 60 of the 90 beds available nationwide. However, since the Taleban took control the cancer department, which had a million-dollar budget, had its funding cut and only functions due to the International Committee of the Red Cross paying staff salaries.

Tuberculosis is a significant health concern, with a current mortality rate of 15.86 per cent according to the WHO, up from 13.42 per cent. Advanced treatment is only available at the Afghan-Japan Hospital in Kabul.

“Life-threatening diseases are going undiagnosed and untreated.”

According to the UN, more than 11,000 individuals in Afghanistan were HIV-positive in 2021. Among these, 1,000 were children, 7,400 were men and 3,000 were women.

However, the Taleban's ministry of public health maintained that only 3,292 people, including 195 children, had been identified as HIV-infected.

Afghanistan is also experiencing a severe mental health crisis. In 2021 alone, over two million individuals sought mental health services at government centres, with many more unable to access treatment.

In October 2022, Human Rights Watch reported that more than half of Afghanistan's population was dealing with depression, anxiety and stress.

Women and girls bear a significant part of this psychological burden, not least because the Taleban's restrictions have prevented them from accessing education, public life and social events.

According to Save the Children, the economic crisis has also pushed families to marry off their daughters at an early age.

Above all, there is a huge lack of qualified medical staff. The Taleban-controlled Afghan Statistics Department reported that in the third quarter of 2022, approximately 8,845 doctors were employed in government health centres. In comparison, during the same period in 2021, there were 10,093 doctors - which dropped to 9,022 by the end of the first quarter of 2022.

A recent WHO report highlighted that the migration of healthcare professionals posed a significant challenge for Afghanistan's healthcare system.

Applications to medical school fell from 1,500 to 150 last year.

There appears to be some implicit acknowledgment of the crisis from Taleban officials themselves. In a virtual meeting with doctors on March 12, 2023, acting health minister Qalandar Ibad said that Afghans spent around half a billion dollars annually on treatment outside Afghanistan.

He presented a plan to recall medical specialists, inviting doctors living abroad to return intermittently to Afghanistan to treat patients. He promised that all travel expenses would be covered by the Taleban government.

Translated by Kazim Ehsan. This report was produced by IWPR partner Etilaat Roz, an award-winning Afghan media outlet.