ISLAMABAD – Prior to the dwindling of foreign aid, a network of hundreds of Afghan midwives was delivering much-needed support to women at their doorsteps in the devastated nation that now faces breakdown.

Now, as Afghanistan grapples with the freeze of its assets in international institutions and shortages of foreign funds with the rise to power of the Taliban, the country’s innovative, but extremely fragile maternal health system faces grim threats of collapse – and with it, the innovative network of midwives.

“Some of our staff are no more showing up for duties mainly due to security concerns, particularly the female trainers and midwives, but others, including male doctors and administrative staff are seriously concerned about of lack of pay and long-term sustainability of the project,” said one official associated with this donor-driven project covering all four zones of the war-ravaged country. The official, interviewed by Health Policy Watch, asked to remain anonymous.

Like an array of public health projects peddled with the help of foreign support in aid-dependent Afghanistan, this unique venture, supported by a European NGO, has hundreds of Afghan male and female doctors, gynaecologists and midwives engaged in at least eight of the country’s 34 provinces.

The thrust of the project is to deliver aid and support to the neediest women in remote and rural areas of the country where access to healthcare facilities remains a challenge. It has engaged, trained and equipped midwives from within these communities for the sake of easy and free access for maternal health.

No medicine, no salaries

The latest assessments by the World Health Organization (WHO) suggest almost two-thirds of clinics and hospitals in Afghanistan have stock-outs of essential medicines and most health workers in the public system have not been paid for months, while the brain drain of highly skilled healthcare workers due to insecurity is beginning to take its toll. 

In Afghanistan, a funding pause by international donors also threatens the continuity of the national ‘Sehatmandi’ programme – which had seen a 28% increase in people receiving essential health, nutrition and reproductive health servivces between 2017-2019.

Meaning “wellness”, the broad-based World Bank-supported initiative with the Afghan Ministry of Public Health, funds some 2,300 Afghan health facilities in 31 out of the country’s 34 provinces, and is a backbone of the national health system, says Dr. Ahmed Al-Mandhari, WHO Regional Director for the Eastern Mediterranean Region. He spoke at a press conference in Geneva on Thursday about the uncertain fate of that public health project and others heavily dependent on aid money.

“The health of women and children of this country will depend on the availability of female doctors, nurses and midwives. We call for a safe and productive work environment for female health workers, and for their ongoing education and training,” the WHO Representative to Afghanistan, Dr. Luo Dapeng told the same virtual press conference.

The concerns come amidst an evident surge in cases of measles and diarrhoea, as well as a resurgence of polio. Up to 50% of children, meanwhile, also are at risk of malnutrition. On top of all this, some 2.1 million doses of COVID-19 vaccine delivered to Afghanistan just prior to the Taliban’s takeover in August, remain unused, health authorities who requested anonymity told Health Policy Watch. 

The country has so far reported to WHO 154,800 cases of COVID-19 and 7,199 deaths.  But since the August takeover by the Taliban there have been significant interruptions to COVID-19 surveillance and testing – meaning that the sharp decline in new case reports seen since 3 August may be highly misleading.  Meanwhile, less than 3% of the population has been vaccinated with a full vaccine course, according to WHO.  

In one of the country’s poorest regions, Ghor province in the central highlands, the local health expert Muhammed Nazem told Health Policy Watch that more than 1,200 children stricken with measles have been referred to the province’s central hospital recently and 21 have died. “Due to the coronavirus and consequent restrictions, we were unable to implement the vaccination campaign against measles. So, for this reason, measles has spread throughout Afghanistan this year, especially in Ghor province,” he said.

Many national and global health experts now fear that the hard-earned gains seen over recent years, including a reduction in maternal and child mortality and moving towards polio eradication, are now at severe risk, with the country’s health system on the brink of collapse.

Engaging the Taliban

Upon concluding a trip to the war-ravaged country and meeting with Taliban leaders, WHO’s Director-General, Dr Tedros Adhanom Ghebreyesus told a press briefing in Geneva on Thursday that engaging with the new government is necessary to support the people of Afghanistan.

“The education of girls is essential for protecting and promoting population health, but also for building Afghanistan’s health workforce of the future,” said Tedros.

For their part, Taliban leaders have promised to remove “impediments” to aid, to protect humanitarian workers, and to safeguard aid offices, according to a 15-point proposal addressed to the UN’s humanitarian aid coordination arm, OCHA, and signed by the Taliban’s acting minister of foreign affairs, Amir Khan Muttaqi.

The 10 September statement, which has been circulating among aid groups this week, also echoed previous pledges to commit to “all rights of women…in the light of religion and culture.”

However, with each passing day, the situation is becoming more and more grim, not only for Afghans in the remote and rural pockets, but also for people in towns and suburban centres where the prices of the medicine in the open market are rising to new heights as the country solely relies on imported medicine.

The president of Afghanistan’s pharmaceutical products trade association, Asad Uullah Kakar, told Health Policy Watch that prices of medicines have surged by 20% due to the closure of banks, disruptions in supplies, and freeze of funds leading to cash-crunch.

Within the communities themselves, health care workers are struggling to cope with the new situation – with noteworthy expressions of courage and determination among professionals determined to continue their routines and their jobs. 

As one senior midwife engaged in a donor-supported maternal and child care training and service project in eight provinces of Afghanistan, told Health Policy Watch, her commitment to saving lives remains strong:

“The whole village knows me and trust me, and I have been helping the women with their maternity issues just like my daughters and sisters. It would be good if these issues (lack of funds) are resolved, but I would never stop helping those I can help.”

Image Credits: Flickr – Canada in Afghanistan, World Bank, WHO.