Decades of war and civil strife have adversely affected the delivery of health services to the population of Afghanistan. Until recently, the network of public service delivery had been disrupted by prolonged war and the lack of a central government. In response, many international and national health-care agencies were responsible to provide prime health services.
There are many barriers to creating an accessible, effective, and sustainable health care system in Afghanistan. The main challenges of rebuilding Afghanistan's health care system include lack of security, lack of infrastructure, economic hardship, poor coordination among government and health care providers, difficult access to health care facilities, unsuitable hospital conditions, and few trained health care workers, especially women.
The lack of infrastructure in Afghanistan is manifested in many ways. Poor road networks and almost complete absence of railways make some rural areas inaccessible during heavy winter snowfalls. Only 6% of Afghans have access to reliable electricity sources. Only 30% of households outside of cities have access to safe drinking water. Improvement of the health care system will require investment in transportation, electricity, safe water, and communications.
Health care quality and resources available vary widely from urban to rural areas. Hospitals outside of Kabul have a difficult time providing anything more than rudimentary care. Patients' bed and other equipment are insufficient. There is even lack of simple thermometers, or record keeping, in hospitals. Electricity is intermittent and running water is usually dirty. Medications for hospitalized patients must be purchased from an outside pharmacy by family members and brought to the hospital. This situation is common throughout the country. If there is medical equipment, most health care workers are not properly trained to operate or maintain it.
Medical laboratories lack supplies and personnel. While primary care remains the appropriate focus of Afghanistan's health care system, hospitals need to be revitalized, especially for the practice of emergency medicine.
Another issue is economic instability. Nearly 70% of Afghans live in extreme poverty with a 32% unemployment rate.
Health care funding mainly comes from outside sources such as the European Commission, World Bank, and USAID. While external funding is key, domestic support of health care must increase. External funding has unpredictable availability, frequent policy shifts, and the potential to end without warning. Improvement in the economy, viable internal funding sources, and more spending by the Afghan government will improve access and affordability of health care.
The Ministry of Public Health contracts with NGOs for the majority of health care in Afghanistan. Although the Ministry and NGOs have improved communication, lack of coordination on a provincial and district level results in inefficient and, at times, duplicated services. The ANA, ANP, and Ministry of Public Health have developed separate but redundant health care facilities to serve specific segments of the population. Lastly, a large number of Afghans use unregulated private sector health care. Integration and coordination among NGOs, the Ministry of Public Health, and various sectors of the Afghan government will be required to create a sustainable health care system for the entire country.
A discussion of health care access improvements is not complete without attention to basic needs. While basic health care is important, the lack of food, clean water, and shelter must also be addressed to improve community health. Due to the recent years of drought and poor food security, nearly 5 million people depend on food assistance from the UN and other relief organizations. Ensuring the population of Afghanistan has adequate food, water, and shelter must keep pace with improving health care access.
Another obstacle for Afghanistan's health care system is the lack of qualified health care workers. During the Taliban years, many health care workers were killed or they fled the country. The "brain drain" on Afghanistan left few health care workers. Of those who remain, medical training is inconsistent because of the lack of standardized training programs. During the 1990s, medical schools were operated according to ethnic and religious rivalry. Consequently, medical students were often admitted through nepotism. The Ministry of Public Health cannot employ those trained by some NGOs because they do not meet the government's strict requirements. As a result, a nationwide survey indicated a shortage of at least 7,000 physicians and 20,000 nurses, midwives, and allied health professionals.
The salary for physicians is too low for a reasonable standard of living, forcing physicians to practice at hospitals or public clinics in the morning and spend the afternoon in private clinics. The few residency training programs that exist provide minimal guidance in terms of lectures, clinical practice, or supervision. Because there are two dominant languages in Afghanistan, courses must be offered in both Dari and Pashto. Upon completion of the programs, few health care workers desire to work in rural areas due to the poor living and working conditions, lack of education for their children, security issues, and poor transportation.
While the number of overall health care workers is improving, the focus must be on women. Afghan societal norms dictate that only women can provide medical care for women. During the Taliban regime, women were forbidden from going to school; thus, virtually no female doctors or nurses were trained during this period. Access to health care for women is improving, but there are still many obstacles to overcome to decrease the health disparities between men and women.
The challenges of establishing a functional health care system in Afghanistan include those of a developing nation, post-conflict nation, and a combat zone. The long-term goal of quality health care for all citizens will only be met by a combination of specific goal-oriented projects, foreign aid, and domestic responsibility.
Health care in Afghanistan is improving as evidenced by improved access to care, enhanced quality of patient care, and more knowledgeable health care workers in rural areas. These improvements show the effects of streamlined cooperation between the Afghan military, civilian government, and NGOs. Unfortunately, the country's health care system still needs significant improvement before it meets basic and higher-level health care needs. The focus on primary care is appropriate; primary care is the first line of defense and yields large dividends.The health care situation in Afghanistan today is dire, but improving. Time and commitment will ensure a brighter, healthier future for the nation of Afghanistan and its people.