Two sets of dogmas contend in Afghanistan: those of the Taliban and the West. Neither side pays the real price for their beliefs. Ordinary Afghans do with their lives. Some aid agencies labour quietly to bring help and hope through a dozen practical ways that bypass competing doctrines. They deserve support.

In March last year, 23-year-old Khatera (pseudonym) went into prolonged labour. Her village clinic in western Afghanistan was long shuttered, and the nearest help was Herat city across a swollen river. Her husband carried her across the raging waters, both submerged to the shoulders. It took them 12 hours to reach the hospital. 

Khatera’s vital signs – and those of her baby – stopped registering hours after reaching the hospital. Why were they not saved? Perhaps no medical equipment or supplies? Perhaps few trained staff? Or perhaps sheer exhaustion?

This everyday tragedy is commonplace for Afghans. Their misfortune is to be squeezed between the beliefs of their Taliban rulers and those of the international community that fled the country. This clash of convictions is fought over the easiest of targets: the defenceless bodies of millions like Khatera.

The outcome is a generation of losers, not just Afghans but those who would save them. As with all lose-lose “games”, the focus quickly shifts to ascribing blame, as in the acres of commentary around the fifth anniversary of the Taliban’s re-accession to power. 

Vital symptoms and signs

Extensive research has established that the fundamental drivers of health outcomes are social determinants. Unsurprisingly, the Taliban’s draconian restrictions that pervert the noble Islamic faith have dealt a crippling blow.

Women have been almost erased from public spaces (except when they are flogged), with restrictions on their movement, education, and employment. Women’s access to health care has shrunk, and very young girls are being forced into marriages to settle debts or relieve poverty.

Let us begin with basic health battlefield statistics. Afghans die young, with a life expectancy of 66.3 years, and under-five child mortality exceeding 50 deaths per 1,000 births – some 40% above the global average. 

Mothers suffer one of the world’s highest mortality ratios at 638 deaths per 100,000 livebirths. All these numbers were improving but have reversed under the Taliban.

Fourteen million Afghans – a third of the population – face crisis-level hunger and there is record-breaking malnutrition with around 4.9 million children and pregnant and breastfeeding women affected. This equates to a tenth of children acutely malnourished and 45% chronically stunted. 

Other conditions – communicable, non-communicable, physical and mental trauma – flourish. Suicide rates, especially among females, are mounting.  Six million coerced refugee returns from Pakistan and Iran, and climate disasters add to the strain.

When levers crumble

All this is familiar. But it is also well known that regimes that claim divine inspiration are not amenable to earthly leverage by traditional aid, trade, diplomatic and military tools, as I discovered in my role as a past special adviser to the United Nations Assistance Mission in Afghanistan (UNAMA). 

Meanwhile, the Taliban are amenable to receiving assistance but on their own terms. That poses a dilemma for those who wish to relieve the suffering of Afghans without supporting their autocratic and misogynistic rulers. 

So the real question in a country that has always been aid-dependent becomes: how to help, also knowing that Taliban regulations complicate aid delivery and utilisation, especially as it is not possible to employ women to reach vulnerable families.

This creates a difficult picture for foreign policymakers, who have many complex problems elsewhere to deal with. With the second coming of the Taliban in 2021, they found it much easier to walk away, whatever the morality of leaving Afghanistan to its own devices in light of the historic responsibilities of external powers in creating the turmoil. 

The walkout, in numbers

The principal consequence of the walkout has been felt in the aid sector. UN-coordinated funding dropped 69% from $3.27 billion in 2022 to $1.01 billion last year. 

Afghanistan’s 2026 humanitarian appeal seeks $1.71 billion. With three-quarters of the year gone, it has received just 30% or $513 million (30 August). 

The health cluster has around $73 million, or 38% of what it wants; nutrition has $51 million (17%), and water, sanitation and hygiene received $19.5 million (12%).

As a consequence, some 445 health facilities closed or suspended operations during 2025 and another 295 in the first half of this year. This includes 203 mobile health and nutrition teams. This means that at least four million people had lifesaving services switched off, including Khatera’s village.

Prevention and public health services also dwindle. The epicentre of wild poliovirus has shifted to Afghanistan with 19 cases this year compared to Pakistan’s three, as house-to-house vaccination stopped in October 2024 and women vaccinators became rare.

Meanwhile, and with no trace of irony, Afghanistan’s de facto Ministry of Public Health has just launched a surreal document with the vision of health as “a fundamental right” and a “goal of care for all Afghans”. 

This is its National Health Strategy 2026-2030 prepared with WHO support. One of its “seven pillars” concerns human resource development. It is not clear how this will be squared with the Taliban bar on women studying medicine, midwifery, nursing, and allied sciences, closing the pipeline for producing the clinicians Afghan women need. 

Does cutting aid kill?

The political economy of aid requires deeper scrutiny. Do aid cuts lead to deaths? The US Secretary of State has asserted that it does not, as the US drastically cut foreign assistance. It is difficult to attribute specific mortality to general loss of aid, especially in Africa where American aid cuts have, in part, been made up by host budgets and other donors.

But the causal association is stronger in Afghanistan, where neither the Taliban authorities nor other donors have stepped in to replace sharply dwindled US assistance, which had peaked above 40% of the country’s humanitarian spend. 

The US gave $728.6 million in 2024, $243.2 million in 2025, and nothing so far in 2026. An interesting study provides frontline evidence of impacts, such as neonatal deaths in Kunar and Farah rising 156% and 167% respectively between 2024 and 2025.

Two sides of the humanitarian red line

But there is a paradoxical aid economy at work. Even with pre-Taliban funding, most aid bypassed the government budget – except for some health basics. 

Since 2021, that has also gone, with UN agencies contracting providers that pay nurses and midwives directly into their personal bank accounts. So cutting such assistance does not defund the Taliban administration but individual health workers.

Thus, the ‘no Taliban support’ dogma costs nothing to their officials standing on one side of the humanitarian red line and everything to the beneficiaries on the other side. No Taliban enforcer misses a meal when yet another aid-funded nutrition site shuts.

Meanwhile, some $4.2 billion of Afghan central bank money sits in a Fund for the Afghan People at a Geneva non-profit foundation that has not disbursed a single dollar since its creation in 2022.  There is a further $3.5 billion frozen in the US and snarled up in post 9/11 litigation. 

And so, Afghanistan’s own money sits idle in Western banks while an ideological contest fires off competing virtue signals over the emaciated and expired bodies of its most vulnerable citizens who were never consulted on any of it.

The wider aid chill

In parallel, aid implementers relying on Western governments remain wary of counter-terrorism law. On paper, there are humanitarian carve-outs including American general licences. But, amidst the friable present mood, who is so rash as to trust a piece of paper?

Apart from cumbersome procedures and added administrative costs around getting waivers, imagine what happens if an agency makes a small payment for rendered services to a doctor who happens to have a Taliban relative, or a local Taliban official demands a small tax on the cash transfer. The agency could inadvertently face the nightmare of legal penalties and criminal prosecution.

Meanwhile, the general donor trend of conditioning humanitarian aid accelerates. Thus, $2 billion US global humanitarian funding via OCHA specifically excludes Afghanistan. Perhaps partly because the Taliban will not agree to a US return to control the strategic Bagram airbase? 

Although the European Commission – now Afghanistan’s biggest donor – has maintained funding levels (around €162 million this year), it also invited the Taliban to Brussels to discuss repatriating failed Afghan asylum seekers. 

With some 500,000 Afghans applying for asylum since the Taliban came, and the increased political toxicity associated with the migration issue, there is a trend towards attaching conditions to European aid.

As Western-espoused humanitarian values sink under their own hypocrisy and the world order splits into ‘the West’ and ‘the Rest’, Afghanistan is finding new friends.

China is courting the Taliban with infrastructure investments in return for accessing Afghanistan’s massive mineral resources. Russia is giving some aid alongside military co-operation to bring Afghanistan into its sphere of influence. Central Asian and Gulf nations, as well as India and Iran, get closer to the Taliban through aid, trade, and diplomacy. This further entrenches the Taliban regime and brings little succour for people.

Creative ways to bypass Taliban

That makes it even more vital to maximise the good effects of available limited humanitarian funding. This translates into aid givers finding creative ways to bypass the Taliban without getting thrown out themselves. 

That high-wire act to stay in the game to do good is the real story from the past five years. It is a tale of the extraordinary resilience of the Afghan people and their own traditional community and social institutions. And a tale of redemption for the very same aid agencies – UN and NGO – that are so heavily criticised for their shortcomings in other corners of the world.

Here are a dozen key strategies learnt from their trial, error and courageous risk-taking that are saving lives here and there in Afghanistan. These deserve scaling up while implementers stay under the Taliban radar as much as possible.

The first is about realising that aid delivery in Afghanistan is a retail affair, not a wholesale business. It requires negotiating for access locally and quietly, knowing that fierce-sounding national decrees are enforced unevenly. Province-by-province technical exemptions, brokered by Afghan staff and elders rather than announced from Geneva or Kabul, have, for example, kept some female vaccinators and midwives working.

Second, more of the dwindling numbers of Afghan professionals could be pressed into service to sustain healthcare frontlines. It means expanding direct-to-worker electronic payments, which would also inject cash into local economies without going through Taliban coffers. Electronic transactions are also easily tracked and audited to encourage small agencies fearing Western anti-terror legislation to expand their services.

Third, pay the mahram, the authorised male required under Taliban restrictions to accompany a female patient or the female health worker going to work. If this offends our Western sensibilities, think of the mahram as staff akin to the clinic watchman or ambulance driver. We are already compromising on mahram in practice while refusing to fund them in principle, which buys us the moral posture and the dead mother alike.

Some communities show incredible creativity with the mahram requirement. For example, groups of women going together to a health centre have negotiated to be escorted by a village elder as their ‘collective mahram’ – thereby allowing their wage-earning husbands, brothers, and sons not to take time off work.

Fourth, where patients cannot travel to clinics, bring them to her. Mobile health and nutrition units are well-known worldwide. Restoring and expanding Afghanistan’s mobile teams whose funding was indiscriminately cut would be a cost-effective boost for healthcare provision.

Fifth, co-locate necessary institutional facilities such as operating rooms, laboratory and diagnostic capacities with existing national, provincial, and district hospitals, and re-equip and re-supply them. This makes it politically difficult for the Taliban to close them. Installing or repairing an ultrasound machine and refurbishing hospital electricity and water saves lives and does not mean condoning the Taliban administration.

Sixth, direct-to-clinic logistics that move vital medicines, therapeutic foods and other supplies from cargo planes to pharmacies under trusted supervision help to minimise diversion and reduce manipulated distribution.

Seventh, investing in autonomous, solar-powered clinic microgrids, including battery storage, has many benefits, not just for preventing the ruin of temperature-sensitive vaccines but also to allow anaesthesia and surgery for common trauma, obstetric, and other emergencies.

Eighth, revive grassroots public health surveillance for marker diseases, hunger and malnutrition, and vital statistics collection around births and deaths. That means paying local community enumerators as done in past smallpox and polio campaigns. It is when operational circumstances are most complex, that programmes cannot afford to go blind from lacking local trend data.

Ninth, take more measured risks. As international humanitarianism retreats while the “duty of care” movement gathers momentum, risk-aversion and institutional self-protection also grow. Understandable, of course, but is this not getting over the top? This is one of the most expressed frustrations by motivated and seasoned aid workers. Risk assessment systems – including utilising AI – have advanced but many agencies are stuck in centralised modes that mistrust well-informed local judgements.

That triggers another thought. With the growing shortage of female Afghan health professionals, could more foreign females volunteer to fill the gap? That raises the associated challenge of their accompanying mahram. There are pragmatic solutions here, including negotiating ad hoc exemptions or facilitating couples to serve together.

Tenth, keep the health and training pipeline rumbling along. Afghanistan’s education sector provides remarkable inspiration through clandestine home and digital schooling initiatives for girls. Can these approaches be applied in the health sector, both for refreshing basic health worker knowledge and for general public education around essential skills such as first aid, nutrition, and preventing and treating common conditions, including psychosocial support and suicide risk handling? 

Further, by investing in enhanced digital connectivity in selected (especially secondary) hospitals via low-cost technologies like Starlink that are available worldwide, expert Afghan medical diaspora with relevant linguistic skills could provide online consultations.

Eleventh, sustaining a health delivery system that works for people is a crucial concern as there is no possibility of political change in the foreseeable future. Meanwhile, high-profile international aid brands and large corporate logos draw intense, negative Taliban scrutiny. 

They could, instead, sponsor low-profile hyper-local community networks via pre-existing local volunteer bodies and underground civic networks to distribute medical micro-assistance, including medicines, hygiene kits, consultation referrals, and even skills training.

Twelfth, and most crucially, health aid givers should agree on common operating rules pragmatically applied in local circumstances. That means less policy rhetoric on confrontational red lines and more about working solutions that focus on patients. 

Facility-by-facility, the Taliban morality inspectors are conceding that medical spaces be demilitarised. Also female and male colleagues may work alongside each other during lifesaving procedures. Such bargains can be built upon.

Consistency and patience are missing

The Taliban rank-and-file know that their loved ones also need healthcare, often under desperate circumstances. Their rigid mindsets are curiously mirrored in their respect for others who also stubbornly hold onto their own principles. Hence, a package of negotiated measures that bring predictable cooperation over health is quite feasible, as shown by pioneering agencies such as Médecins Sans Frontières.   

In short, much more can be done to safeguard the health of Afghans despite numerous obstacles. There is nothing novel in the proposed approaches that have already shown good results in Afghanistan and other complex resource-poor contexts.

So what is missing? Beyond insufficient resources, it is a sense of coherent mission that believes in the feasibility of improving the health chances of Afghans. This will not come from the current defeatist attitudes among humanitarian, global health, and multilateral aid communities with low expectations and marked risk aversion. Neither will it come from composing national health strategies that are little more than fantasies. 

We need pragmatic but consistent labouring from the bottom-up organised around whatever Afghans find feasible. Above all is the requirement for patience that the international community is not known for.

 

Mukesh Kapila is professor emeritus of global health and humanitarian affairs at the University of Manchester, and a board member of Health Policy Watch. Vital Signs in Global Health is a regular column, and the opinions expressed are solely those of the author. 

Image Credits: Charlotte Cans/ UNOCHA, Karimi/ UNICEF Afghanistan, WHO EMRO, WHO.