On life support
Afghanistan’s health-care system is crumbling
Staff have gone unpaid for months and essential supplies are running out
ABDUL QASIM SANGIN’S medical career began with the fall of the Taliban government in 2001. He is not sure it can survive their return. Dr Sangin was a final-year student in Kabul when America ousted the Islamists from power two decades ago. He has since risen to become the director of a provincial hospital. Yet in just the four months since the tables turned and the Taliban retook the country, his clinic has become a shadow of its former self.
Staff kept Charikar hospital, an hour’s drive north of Kabul, open throughout the Taliban takeover. But they are at breaking-point. Salaries have not been paid in six months, leaving nurses without even the bus fare to get to work. There is no money to pay for medical supplies or food. “This hospital is unfortunately not the same hospital it was four months ago,” says the doctor.
Three-quarters of the Afghan government budget was met by foreign donors until the Taliban’s march on Kabul in August. That funding stopped overnight as donors balked at bankrolling a regime that retains links with al-Qaeda and prevents girls from going to secondary school, among other characteristics. Yet without foreign cash the fragile state built at great expense over two decades is quickly collapsing. Health care is an obvious casualty. Hospitals across the country are closing or running short of basic supplies including fuel, food and medicine. The whole government payroll has frozen, throwing millions into instant poverty. The IMF is predicting an economic contraction of up to 30%.
Salaries were often not paid promptly under the previous government, despite foreign largesse, but staff have never gone without for so long. Dr Sangin says his hospital remains open only because of the dedication of his staff and supply deals cut with local traders who want the town to retain some health care.
Fixing the mess is now the responsibility of the Taliban. As insurgents, they boasted they would run a less corrupt administration than that of Ashraf Ghani, the president who later fled when the Taliban took over. They used to deliver services in territory they controlled by piggybacking on Kabul’s capacity, allowing centrally funded doctors and teachers to continue as long as they abided by the Taliban’s strict codes. Now the new government must run the entire show with no money. Its officials are noticeably less sanguine than in the heady days after victory.
Overseeing Charikar’s hospital is the local health chief for Parwan province, a Talib named Maulvi Mohammad Nader Haqqani. Medical staff are sniffy about his professional credentials, saying he is just a mullah, but they are grateful he has not tried to interfere in the running of the hospital. Maulvi Haqqani says his experience comes from years of directing health care for wounded Taliban fighters, getting them patched up in underground hospitals by sympathetic doctors.
The blame for the dismal state of health care in Afghanistan, he says, lies with the foreigners and the former government: “The biggest problem is that the foreigners have frozen our funds. People do not have the economic power to buy their prescriptions. The former government has left us with a lot of debts.”
Aid agencies are attempting to fill the gap. The Red Cross says it has begun paying for running costs, medicines and supplies in 23 regional and provincial hospitals employing nearly 8,000 staff. The United Nations is meanwhile paying $45m to keep 2,331 hospitals and clinics going from November 2021 to January 2022; that money includes salaries for around 25,000 health workers. Staff at hospitals in Herat and Kabul said in early December that they had received salaries for the first time since the summer, paid for by the Red Cross. Some frozen government funding is being switched to humanitarian aid.
Yet such measures are piecemeal and will not refloat the economy, which is paralysed by sanctions. International objections to funding the new state, or removing those sanctions, remain. America and France are particularly stubborn, according to one diplomat. “We’ve been told: ‘If you can support the people without in any way cementing the regime, then go for it, but it’s no longer about supporting the state,” the diplomat says.
Meanwhile Dr Sangin receives a stream of petitioners, each needing his signature to apply for medical-treatment visas to Pakistan or Iran. He expects few to return, and becomes emotional thinking about his own prospects. His family want to leave, but he knows a fresh start as a refugee could lose him his career and status. “We don’t want to leave our country. I have a good life, a good reputation, respect here. But I know that finally I will be obliged to accept the conditions in a foreign country.”