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Living with a health system devastated by decades of conflict, many Afghans are struggling to access essential healthcare services, according to a new report.
Barriers including costs and distance mean that many face severe obstacles accessing emergency, critical and maternal care—key components of a functioning health system, according to research conducted by the humanitarian medical non-profit EMERGENCY, which has been operating in Afghanistan since 1999, and the Università del Piemonte Orientale’s Center for Research and Training in Disaster Medicine, Humanitarian Aid and Global Health (CRIMEDIM).
Based on surveys and interviews from over 1,600 Afghan patients, caregivers and medical staff across 11 provinces, the new report “Access to Emergency, Critical, and Operative Care in Afghanistan” offers an in-depth look at barriers to healthcare in Afghanistan, from the perspective of the Afghan people.
Thanks to improved mobility across the country following the end of conflict, an increasing number of Afghans are seeking healthcare services; yet after decades of resources directed toward military and defence, Afghanistan’s healthcare infrastructure is unable to meet the growing needs of the population—including trauma and obstetric emergencies, intensive care, life support systems and surgical operations.
“The Afghan people suffered debilitating health insecurity through decades of conflict, and now in the face of joint economic and humanitarian crises,” said Rossella Miccio, President of EMERGENCY. “For this report, the research team spoke to patients, their families, and colleagues across our surgical hospitals and primary care clinics, as well as staff at government-run hospitals, in order to understand, first-hand from the Afghan people, exactly what barriers are preventing them from accessing the healthcare services that could save their lives.”
Emergency, critical and operative care services are vital in achieving Universal Health Coverage and enhancing health system resilience, the report says, echoing The Lancet Commission on Global Surgery. Limited access often results in preventable deaths.
Afghanistan faces an evolving disease burden: the prevalence of noncommunicable diseases is increasing, rates of trauma-related injuries remain high, while women consistently face some of the worst maternal health risks in the world. Yet despite the clear and expanding need, the report claims, Afghanistan’s emergency, critical and operative care services are largely insufficient after decades of violence and underinvestment, from infrastructure and workforce inadequacies to the heavy burdens placed on those seeking care.
Physical barriers prove one of the most difficult for patients to overcome: just over 2% of those surveyed said they were able to use a public ambulance to access health services, while nearly half—many of whom live in Afghanistan’s mountainous rural areas—travelled on foot.
When facilities are reached, they often lack the staff or equipment needed to provide care safely. In an interview for the report, a doctor from a government-run provincial hospital in Helmand, southern Afghanistan, commented, “Sometimes the power goes out in the middle of surgery. We use phone flashlights or wait until the generator starts. It’s dangerous for the patient.”
As a consequence of such widespread historic neglect of the public healthcare system, 79% of respondents were forced to travel to another city, province or even another country for surgical care. For those seeking maternal healthcare, the percentage reached 76%, with two-thirds of women respondents needing to travel to access the services they need.
Yet the years-long economic crisis is compounding the barriers in infrastructure. Asked the Chief Surgeon at a public hospital in Kabul, “There are communities or households according to my experience that can’t even afford the money for the fuel or to get a car and to reach the hospital, how can they do [so] during an emergency?”
Facing this widespread series of overlapping obstacles, one in four patients were forced to postpone a surgical operation at least once, the report finds, while one in five has missed a follow-up appointment. Delaying essential care frequently leads to worse health outcomes, in turn putting an even greater strain on the health system: over 33% of those surveyed reported a disability or death due to delayed care.
Socio-cultural factors also play a role in limiting access to care. Women, especially widows, are more likely to be scared when accessing healthcare than men, and face additional delays due to restrictive gender norms. They may not disclose health conditions until they are severe, while expectations of being treated by female health practitioners limit treatment options.
Obstetric and maternal conditions are of particular concern: one in five Afghan women is unsure if she has experienced pregnancy loss, while nearly one in four knows of a maternal death during pregnancy.
Commented the Chief Gynaecologist at the provincial hospital in Laghman, east of Kabul, “We have a lot of emergencies, but often there’s no female doctor available, especially at night. Families sometimes prefer to wait until morning rather than let their daughters be seen by a male doctor.”
Based on suggestions from the surveyed Afghan patients, caregivers and healthcare providers, the report concludes with 10 key recommendations for improving the country’s health system.
“It’s important to adopt a whole-of-health-system approach, from community to primary to hospital care, to ensure physically accessible facilities, properly trained staff, a functioning inter-hospital referral system—free of charge to the patient,” says Ms. Miccio.
“Taking a longer perspective, the bans on girls’ and women’s rights to education and work not only threatens the future of women’s healthcare in Afghanistan, but the future of the entire country. We urge the authorities to rescind them. Meanwhile, the needs remain immense. The international community should adopt a nexus approach connecting humanitarian, development and peace initiatives in order to ensure the long-term sustainability of the health system. We cannot forget Afghanistan.”
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EMERGENCY operates three surgical hospitals, a maternity centre and more than 40 clinics across Afghanistan, integrated within the public health referral network.
The report, “Access to Emergency, Critical, and Operative Care in Afghanistan,” surveyed 1,551 patients and 32 staff at EMERGENCY hospitals and clinics, as well as 20 healthcare workers at government-run hospitals; altogether, 11 of Afghanistan’s 34 provinces are represented.