BETWEEN RHETORIC AND REALITYTHE ONgOINg STRuggLE TO ACCESS HEALTHCARE IN AfgHANISTANFebruary 2014

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Ahmad Shah Baba District Hospital, Kabul• MSFsupportingMinistryofPublicHealth

hospitalsince2009• 69beds• Outpatient,inpatient,maternity,emergency,

surgery,paediatrics,therapeuticfeedingandmobileclinicsservices

• Everymonth: 9100outpatientconsultations 4400ERconsultations 1300admissions 1050deliveries 90surgeries

Boost Provincial Hospital, Lashkar Gah, Helmand• MSFsupportingMinistryofPublicHealthhospital

since2009• 250beds• Inpatient,maternity,emergency,surgery,paediatric

andtherapeuticfeedingservices• Everymonth: 5400ERconsultations 900admissions 740deliveries 470surgeries

Kunduz Trauma Centre• FullyoperatedandmanagedbyMSFsince2011• 62beds• Surgicalcareforgeneraltraumaandconflict-related

injuries• Everymonth: 1400ERconsultations 310admissions 300surgeries

Khost Maternity Hospital• FullyoperatedandmanagedbyMSFsince2012• 83beds• Specialisedmaternalandneonatalcare• Everymonth: 1100admissions 1000deliveries 45surgeries

MSFINAFGHANISTANMédecinsSansFrontières(MSF)isamedicalhumanitarianorganisationthatoperatesundertheprinciplesofindependence,impartialityandneutrality.

MSFhasbeenworkinginAfghanistansincetheearly1980s.FollowingtwodecadesofemergencymedicalcareprovisioninAfghanistan,MSFleftthecountryin2004afterthebrutalmurderoffiveofourcolleagues.MSFreturnedin2009ashumanitarianneedshadmarkedlyincreased,alongwiththedeterioratingsecurityconditions.

MSFrunsasurgicaltraumacentreinKunduzinthenorth,aswellasamaternityhospitalinKhosttotheeastofthecountry.MSFalsoworkstosupporttheAfghanMinistryofPublicHealthinAhmadShahBabaHospitalineasternKabul,andinBoostHospitalinLashkarGah,inHelmandinthesouth.InalllocationsMSFprovidesqualitymedicalcarefreeofcharge.

MSFcurrentlyhas1,600Afghanstaffand70internationalstaffworkinginthecountry.InAfghanistanMSFreliesonprivatefundingonlyanddoesnotacceptfundsfromanygovernmentforitswork.

Uzbekistan

Turkmenistan

Iran

Pakistan

Tajikistan

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EXECUTIVE SUMMARY 6

INTRODUCTION 11

METHODOLOGY 12

AFGHANISTAN : THE ONGOING wAR 14

Violenceescalatinghumanitarianneeds 15

thepoliticsofaidinwar 16

selectiVestorytellingandthehealthsystem 18

BARRIERS TO ACCESS TO HEALTHCARE 20

warandinsecurity 21

distance 28

cost 31

gapsinthehealthsystem 36

lackofrespectformedicalfacilitiesandhealthworkers 41

CONCLUSION 48

ACRONYMS 51

END NOTES 52

CONTENTS©

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EXECUTIVESUMMARY

2014isanothercrucialyearforAfghanistan:after12years, theUS-ledNATOmilitary interventionin the country has entered its final phase,and presidential and provincial elections arescheduledforApril.Asthebulkofinternationaltroopswithdrawbeforetheendoftheyear,theworld’s attention is rapidly turning elsewhere.What interest remains in Afghanistan is firmlyfixed on military drawdown, security transitionand pre-electoral wrangling. ConspicuouslylackingisafocusonthedailyrealityforAfghans,trapped in an escalating conflict – indeed 2013wasreportedlythesecondmostviolentyearforcivilianssince2001.

As coalition forces pull out, their leadersattempttodefinethelegacyoftheinternationalintervention in Afghanistan. Alluring narrativesofsuccess–craftedtosuitpoliticalandmilitary

agendas–abound.Whenitcomestohealthcareprovision, much investment and progress hasundoubtedly been made since 2002. However,officialaccountsofAfghanistan’shealthsystemhabituallyemphasiseachievements,yetneglectunmetmedicalhumanitarianneeds.

For MSF, the overly optimistic rhetoric abouthealthcare success often diverges significantlyfrom the reality our teams see on the ground.However, a dearth of reliable statistics makesit difficult to gain a comprehensive view of thetrue extent of needs. To build a clearer pictureof people’s ability to access healthcare, MSFconducted research in the four hospitals whereour medical teams work – in Helmand, Kabul,Khost and Kunduz provinces. Over a six-monthperiod,asurveyandinterviewswerecarriedoutwithmorethan800patientsandtheircaretakers

KEY FINDINGS:

Impact of ongoing violence and insecurity

-Within the previous 12 months, one in fourpeople(29%)hadeitherexperiencedviolencethemselves,orhadafamilymemberorfriendwhohadexperiencedviolence.

-Oneinfourpeople(23%)hadafamilymemberorfriendwhohaddiedasaresultofviolencewithintheprecedingyear.

-The vast majority (87%) of the violence anddeathswerecausedbythecontinuingarmedconflict. The remaining deaths and violenceweretheresultofcriminalityorpersonalorcommunalfeuds.

tohelpbetterunderstandtheextentofthebarrierspeoplefacewhentryingtoobtainmedicalcare.

The results are grim. Statistics and personalaccounts highlight the devastating impact of theongoingwaronAfghancommunities.Inacountrywith some of the highest mortality rates in theworld,theconflictiscausingwidespreaddisruptiontohealthservices,particularlyinremoteareas.

People’sstoriesrevealthewar’stolloncivilians:anentirefamilyblownupbyalandmineastheytravelled home from hospital with a new baby;villages caught between the attacks and thedemandsofmultiplerivalarmedgroups;peopleforced to hold night-long ‘death watches’ oversick or injured loved ones as fighting ragesoutside, in thehopeofsafely reachingmedicalcarethenextday.

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Impact of lack of access to healthcare-Oneinfivepeople(19%)hadafamilymember

or close friend who had died as a result oftheir lackofaccess tohealthcarewithin thepreceding12months.

-The three main barriers to accessinghealthcare,whichhadresultedinsubsequentdeath, were: lack of money and high costs(32%); long distances (22%); the armedconflict(18%).

Dangerous journey to healthcare

-For those who managed to reach a healthfacility,variousobstacleshadtobeovercome.Themainobstacleforoneintwopeople(49%)wasrelatedtotheconflict.

-Eventhoughthoseinterviewedhadmadeittohospitalontheoccasionofthesurvey,oneineightpeoplereportedthatonotheroccasionsduringtheprecedingyeartheyhadnotbeensolucky.InHelmandandKunduz,twoinfivepeople reported that obstacles had eithercompletelyblockedthemorseriouslydelayedthem from reaching MSF health facilities atleastonceduringtheprecedingyear.

-Threetimesoutoffour(74%),theobstaclethathaddelayedorblockedthemfromtravellingto an MSF hospital was active fighting orinsecurityatnight.

Distance and cost as barriers

-Distance was a major barrier to patientsreaching health facilities in all locations. InKabul and Kunduz, it was cited by patientsas the main obstacle. One third of thoseinterviewedinKunduzreportedthatdistancehadbeenasignificantdifficultywhenbringingwoundedpatientsforemergencycare.

-Oneintenpeople(12%)hadtravelledformorethan two hours by motor transport, often onperiloustracksandroads,toreachhospital.InKunduz,oneinfourpeople(27%)hadtravelledfor more than two hours with a seriouslyinjuredpersontoreachthetraumacentre.

-Two in three people (66%) described theirhousehold as poor to extremely poor, livingon around US$1 a day. Yet people had paidanaverageofUS$40forhealthcareduringarecentillnessintheirhousehold,withoneinfourspendingmorethanUS$114.

-Two in five people (44%) had been forcedto borrow money or sell goods to obtainhealthcareduringarecentillness.

Perceptions and use of the health system-Four in five people (79%) had bypassed

their closest public clinic during a previousillnessintheprecedingthreemonths,mostlybecause they believed there were problemswiththeavailabilityorqualityofstaff,servicesortreatmentsfoundthere.

These findings confirm that prevailing successstories about the health system frequentlymask the extent of the barriers impedingaccesstoaffordable,qualitymedicalassistancefor too many Afghans. The majority of peopleinterviewedsaidtheystruggletoaccessmedicalcare,duetoacombinationofinsecurity,distanceandhighcosts.

Although the number of health facilities inAfghanistan has increased considerably overthe past decade, people reveal that there arestill too few affordable or properly functioninghealthfacilitiesthattheytrustclosetothem.Afocusonimprovingbothcoverageandqualityofhealthfacilitiesisnecessary,particularlyinthemostinsecureareas,wherebasicandlifesavingmedicalcareisoftennon-existent,prohibitivelyexpensiveorinaccessible.

For those who do manage to reach healthfacilities, their journeys are often fraught withfearanddangerastheycontendwithlandmines,roadblocks, checkpoints, harassment andcrossfire. Paying large amounts to cover thesejourneys, as well as paying for doctors’ fees,medicines, laboratory tests and inpatient care,pushes many people into untenable debt. Aspromisedunderthenationalfreecarepolicy, itisthuscriticalthatpublichealthcentresensurefreemedicalcareisavailabletoeveryone.

With the number of people treated for woundsinflicted by weapons in Afghanistan rising by60% in 2013, the lack of services and facilitiesfor thoseaffectedby the intensifyingconflict isespeciallyconcerning.Inparticular,theabsenceof a properly functioning referral systembetween basic health centres and district orprovincialhospitalspreventswoundedcivilians,orwomenexperiencingcomplicationsinlabour,fromaccessingcriticalsurgicalcare.

Allpartiestotheconflict,aswellasarangeofcriminalgroups,continuetoengageinactivitiesthat create obstacles to accessing healthcare.Active fighting, the occupation of healthfacilities by armed groups, deliberate delaysand harassment at checkpoints, and attackson medical vehicles and personnel all createunacceptable barriers for sick or woundedpeopleinneedofmedicalassistance.

The announcement by the Government ofAfghanistan that a number of health facilities,along with schools, have been designated asregistration centres and polling stations forthis year’s election is a further sign of healthfacilities being used for purposes other thanmeetingmedicalneeds.Thisplaces thehealthfacilitiesatincreasedriskofattack,damagestheperceptionofhealthcentresasneutralspacestoprovidemedicalcare,andputsthelivesofhealthworkersandpatientsindanger.

While destruction and disruption of servicesdisproportionatelyaffectsthoselivinginremoteconflict-affected areas, the insecurity alsoprevents international humanitarian agencies,including MSF, from providing a sustained oradequate response in these locations. Thismeans the most vulnerable people are left tofendforthemselves.

Tobetterensurethatqualitycarereachesthosecommunitiesmostinneed,itisvitalthathealthandhumanitarianorganisationsprioritisenegotiating

theiraccesswithallsidesinthearmedconflict.Atthesametime,allpartiestotheconflictmustdofarmoretoensurethatneutralandimpartialcare can be safely provided to wounded andsick people, including those actively involved inhostilities.

Over the past decade, decisions on whereand how to provide assistance have too oftenbeen based on desires for stabilisation, forceprotectionor‘winningheartsandminds’,attheexpenseofadequatelyaddressingpeople’smostpressingneeds.Everyeffortneeds tobemadeto untangle humanitarian aid and action frompoliticalandmilitaryobjectives.

It is striking how far the accounts of ordinaryAfghans differ from prevailing narratives ofprogress.Packagingtheinterventionintoasimplesuccess story risks obscuring the reality of theongoingwarandpeople’sincreasinghumanitarianneeds. MSF’s report highlights the experiencesofourpatients inordertogalvaniseanimprovedresponse to their situation. MSF remainscommitted to providing free, quality care in allthelocationswherewework,andwillcontinuetostrivetoreachthemostvulnerablepeople.

As troops pack their bags, and donor andmedia interest in the country wanes, it is vitalto prioritise actions that can deliver tangibleresults for the Afghan population. Now is thetimetofaceuptotherealityoftheirsituationinordertosavelivesandalleviatetheirsuffering.

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Embroiledinwarforalmost35years,Afghanistanis locked in a complex crisis with staggeringeconomic, political and social problems. 2013was reportedly one of the most violent yearssince the US-led NATO military interventionbeganin2001.

By the end of 2014, the bulk of US and Britishsoldiers are expected to withdraw, with theNATO-ledInternationalSecurityandAssistanceForces (ISAF) having finalised the handover oftotal responsibility for security to the AfghanNationalSecurityForces(ANSF)in2013.

Provided a bilateral security agreement (BSA)is approved between the US and Afghanistan,theUSisexpectedtokeepanestimated10,000troopsinAfghanistan,withNATOalliesprovidingadditional troop support after 2014. However,talks around the BSA have stalled, fuellinguncertainty about what post-2014 will bring. Atthesametime,criticalpresidentialandprovincialcouncilelectionsareslatedforearlyApril2014.

Inthemeantime,hardlyaweekpasseswithoutcasualtiesorsevereinjuriesfrombombattacks,shootings, landmines or drones. Humanitarianneedscontinuetogrow,astheongoingconflictexertsadevastatingtollonthecivilianpopulation.

As the Coalition Forces pull out, their leadersstruggle to define the intervention’s legacy inAfghanistan. Alluring narratives of success –crafted to suit political and military agendas– abound. The world’s attention is firmly fixedon military drawdown, security handover andpre-electoralwrangling,withthedailybattletosurviveforhundredsofthousandsofpeopletoooftenrelegatedfromtheheadlines.

In the search for a success story, healthcareis repeatedly held up as a glowing example ofstate-buildingefforts.Eventhoughprogresshasundoubtedlybeenmadeinhealthcareprovisionsince2001,reportedratesofmaternalandinfantmortality in Afghanistan remain among thehighestintheworld,casualtiesfromviolencearemounting,andunmetmedicalandhumanitarianneedscontinuetosoar.

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INTRODUCTION

Adearthofreliablestatisticsmakesitimpos-sibletogainaclearpictureofthetrueextentof suffering in numerous areas of the coun-try.Muchoftheavailabledataiseitherweak,disputedorexcludesthemostinsecureareas.This is compounded by the fact that accessforhumanitarianorganisationstoremoteandinsecure areas has been shrinking over thelastdecade.Manyaidprovidersarebunkeredinsidemaincitiesandtowns,unabletodeliverormonitorassistanceininsecurezones.

MSF’sownexperiencebeforeandsinceits2009returntoAfghanistanisthattheupbeatrhetoricabout internationally supported gains in thehealthsystemoftendivergessignificantlyfromthe reality on the ground. In an effort to buildamorecomprehensiveandinformedpictureoftherealityofpeople’slivesandtheircapacitytoobtain quality, affordable medical assistance,MSF conducted a survey and interviews withhundredsofpeopleoversixmonths in2013 inallthehospitallocationswhereitsteamswork.The statistics and personal accounts from thefourprovincespaintagrimpicture,illustratingthe extent of the war’s devastating impact onthosetryingtoaccesshealthcare.

The research exposes the reality for com-munitiesintheseprovincestrappedbetweenmultiple sides in an unpredictable, violentconflict: long perilous journeys risking lifeand limb to get malnourished babies, preg-nantwomenorinjuredloved-onestomedicalaid; clinics without enough drugs, qualifiedstaff or electricity; abandoned developmentprojectsincludinghalf-constructedhospitals;mounting debt to pay for treatment; and thedistressing impact that decades of violenceandinsecurity ishavingonpeople’smaterialandmentalstates.

With the conflict spreading to once-stableareasofthecountry,andominousindicationsthatthewarwillonlyintensifyinmanyplaces,alongwithlawlessnessanddisplacement,thehumanitarian situation in Afghanistan todaycannotbeoverlooked.Withthisresearch,MSFhopes to shed greater light on the real andunmetmedicalhumanitarianneedsofsickorwoundedAfghans.Itisessentialthattherealityoftheirlivesplaysalargerroleindefininghowinternational donors, the Afghan authoritiesand aid providers can better meet people’shealthcareneedsinthiscomplexconflict.

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OBjECTIvES:The main objective of this research was togenerate insight into the barriers to accessinghealthcare through existing health structures,asaresultofthecurrentcontext,conflictandaidsysteminAfghanistan,inorderto:• Deepen MSF’s understanding of the context

andrealitiesfacednotonlybyourpatientsbutalsotheirfamiliesandcommunities.

• EnsurethatMSF’soperationsremainorientedto respond to people’s most pressing healthneeds.

• Raise awareness of the continuing humani-tarianandmedicalsituationinAfghanistan.

• SharethefindingswithotheractorsinvolvedinAfghanistantofeedintoreflectionsonhowtoimproveaccesstoessentialhealthcareforthosemostinneed.

METHODS: The methods of information collection frompatient sources used between mid-June andend-October2013:• Cross-sectional survey among 700 patients

(or caretakers) in four different provinces(Kabul,Kunduz,KhostandHelmand),usingaquantitative,pre-testedquestionnaire.

• 12 semi-structured focus group discussionsamongpatients(orcaretakers),withsimilarbackground/characteristicsinfourlocations.

• 35semi-structuredindividualinterviewswithpatients (orcaretakers),withaminimumofeightindividualinterviewsineachofthefourlocations.

Additionalinformationwascollectedfrom:• Health data and indicators from medical

reports of health structures supported byMSF.

• Several interviews with key interlocutorswithin each of the four locations and atcountry level, exploring national policy andcontextualfactors.

• Brief literature review on health servicesin Afghanistan since 2001, including greyliterature.

LOCATIONS:Data collection was exclusively conducted inlocations where MSF operates and amongpatients and caretakers within health facilitiesrunorsupportedbyMSF.

DETAILS OF PATIENT SAMPLING:In each project location, a minimum of 175questionnaires were completed, and eightsemi-structured individual interviews, andbetweenthreeandfivefocusgroupswereheld.The sample size (n=175) from each of the fourprovinceswaschosentogetsufficientstatisticalpower to compare patients from inside andoutside the district where the hospital waslocatedinaparticularprovince,butalsotodrawcomparisons between the provinces. Patientsandcaretakersfromalldepartmentswithinthefour hospitals were interviewed. Conveniencesampling was used, either in the wards or inoutpatientconsultationareas.Theonlyselectioncriteria for participants was whether they hadsomeoneelse in theirhousehold–besides theone currently in care – who had been sick orinjuredinthepastthreemonths.

For the semi-structured individual interviews,participantswereaskediftheywantedtocontinuethe interview once they had completed thequestionnaire.Forthefocusgroups,participantswere divided into male and female for culturalreasons.Participantswereattributedtoagroupbased on rural versus urban origin and onwhethertheywerelivinginoroutsidethedistrictwhere the hospital was located. Each focusgrouphadaminimumoffiveandamaximumoftenpeople.TheResearchCoordinatorfacilitatedeach focus group, with conversations usuallyheld in Pashtu translated by a male or femaleAfghaninterviewer.

METHODOLOGY

DATA COLLECTION:An MSF Research Coordinator supervised theresearch in the four project locations. ThreemaleandthreefemaleAfghaninterviewerswererecruited,toconductsurveysandinterviewsformale and female interviewees respectively. Allinterviewers were trained over one day. Theyadministered the questionnaire in the relevantlocal language(predominantlyeitherPashtoorDari). The questionnaire was tested in AhmadShah Baba hospital in Kabul. In each projectlocation, the research work was carried outwithin15workingdays.

DATA ANALYSIS:ThedataretrievedfromthequestionnairesfromthefourprojectlocationswasenteredinanExceldatabasebetweenOctoberandNovember2013.Somevariableswerecategorisedtofacilitatetheanalyses. The median and interquartile ranges(IQR)werecalculatedfornumericvariablesandproportions for numerical variables. AnalyseswereperformedwithStata(version11.2).Focusgroup discussions and individual interviewswere transcribed by the Research Coordinator.Thegroundedtheoryapproachwasemployedfordataanalysis.

ETHICS AND CONSENT:All interviewees gave informed oral consent toparticipate.Individualresponsesweretreatedinsuchawayastoassureconfidentialityandnon-traceability.AgreementtoconducttheresearchinMinistryofPublicHealth(MoPH)hospitalsinKabul and Helmand was sought and receivedfromtheMoPHinbothlocations.

LIMITATIONS AND POTENTIAL BIAS:TheassessmentsweremadeinfourlocationsinKabul, Kunduz, Khost and Helmand provinces.These locations were chosen on the basisof MSF’s presence there, and in hospitalssupported or run by MSF. Security conditionsmeantitwasimpossiblefortheresearchteamtorunapopulation-basedassessmentinthewidercommunity.

The results of these assessments cannotthereforebeextrapolatedascountrywideresults.Nevertheless, the view they provide from thefourlocationscangiveareasonableindicationofsome of the access barriers to healthcare thatpeoplemightfaceinotherareasofAfghanistan.

The sample of people interviewed was all withpatients or caretakers within MSF-supportedhealth facilities, except for one day of semi-structured interviews with a mobile clinicteam in Kabul. This likely resulted in selectionbias as patients surveyed already had accessto healthcare, having managed to reach thehospital where MSF was working. Thus, theresearch likely underestimates the extent andtype of barriers facing those who might nevermakeittoanMSFhospital.

Moreover, thefact thatallof thefourhospitalsarelocatedinthemaincityinthecentraldistrictoftheirrespectiveprovincesintroducesanotherpossiblebiasofurbanversusruralpopulation.

Inordertoreduceuserselectionbias,patientswere questioned about the health seekingbehaviourandresultsforotherindividualsinthehousehold during a previous period of illness,i.e.adifferentpersonthanthecurrentpatientincareatthetimeoftheinterview,withadifferentillnessthanthecurrentreasonforseekingcare.While this reduces bias towards householdsrelatively more likely to access healthcare, itcannotentirelyeliminateit.

Inaddition,peoplesurveyedknewthisresearchwas being done by MSF, which could alsointroduce possible social desirability bias intothe research. Furthermore, data were notalwayscomplete forall thevariablescollected,which potentially resulted in non-respondentbias.Finally, incertainplacesinthisreportweanalyse subsets of the interviewed population,whichcansometimesresult insmallnumbers,leading toan increasedprobability thatchanceinfluencesthosefindings.

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AFGHANISTAN:THEONGOINGWAR

Afghanistanisacountryatwar,withlargeswathesofitsterritoryengulfedinviolence.Despitesomepositivedevelopmentsoverthepast13years,itre-mainsahighlyaid-dependentstate,characterisedby widespread poverty, illiteracy, unemployment,corruption,1aweakformaleconomyandagrowinginformalandillegaleconomy.

By2010,morethanUS$30billionworthofdevel-opment and humanitarian assistance had beeninjected into the country, and almost ten timesas much in military aid.2 However, Afghanistanranks175outof186countriesandterritoriesonthe Human Development Index;3 and seventh-worstcountryof 160,basedon theextentof itshumanitarianneedsandvulnerability.4

Armed conflict continues to rage between theGovernment of Afghanistan (GoA), togetherwith its internationalallies,andvariousarmedopposition groups (AOGs). 2013’s traditional‘fightingseason’,fromearlyApriluntilOctober,sawapurported41%increaseinthenumberofattacksbyAOGscomparedtothepreviousyear.5Taking full combat lead from the internationalcoalition security forces mid-year, the AfghanNational Security Forces (ANSF) sufferedhigh numbers of casualties in 2013, with a79% increase compared to the previous year’sfighting season.6 Far from being defeated, theinsurgencyhasvowedtocontinuetoescalateitsarmedopposition.

“All my children grew up withthiswar.Theyaresomehowusedto the fighting and bombing. Ofcourse theyareafraid,but theyknow that they need to stay in-sideandnevertogooutoftheirroomincaseabulletorarockethitsthem.Theyknowwhattodowhenthefightingishere.”Female,23years,displacedtoGirishkdistrictbyviolenceinNadAli,Helmandprovince

“Thisfightingseasonisbad.Everyoneis thickening and raising the wallsaround their homes. We’re trying tobuild them up from three metres tofive metres, so the rockets and thebullets don’t enter our houses. Now,when the bullets fly, they meet thewallinsteadofmyfamily.”Male,40years,farmer,NadAlidistrict,Helmandprovince

Thewithdrawalofinternationalcombattroopsisexpectedtobringasharpdeflationofthefiscalwar bubble, as lucrative businesses proppedup by military spending crumble. Eighty-fivepercent of the Afghan public budget comesfromabroad,withthevastmajorityflowingintothe security sector.7 The Afghan economy hadbeengrowingbynearly10%annually inrecentyears,butsawthatdropto3.1%in2013.8

Growth in the economy is forecast to tumblefurther,largelyasaresultofthedeclineinfor-eign aid,9 including international developmentassistance, despite pledges from internationaldonors at the 2012 Tokyo Conference.10 This isworrying for a country with an unemploymentratehoveringbetween35and40%11,12andwheremorethanone-thirdofthepopulationlivesbe-lowthepovertyline.13

In 2012 all humanitarian aid for Afghanistansunk by half.14 Between 2010 and 2012, USAIDcontributions forAfghanistanalready fell fromUS$4.5to$1.8billion.15Atthestartof2014theUS Congress announced its intention to slashdevelopmentaidbyhalfinthecomingyears.16,17Any serious reduction in development andhumanitarian assistance would be profoundlydisruptive, placing further stress on thecountry’seconomy,aswellasadverselyaffectingessentialhumanitariananddevelopmentwork.

vIOLENCE ESCALATING HuMANITArIAN NEEDS “TheTaliban,the internationalforcesand the army are enemies to eachother. But every day, it is more thantheseenemiesthatdie.Everyday,itisthecommonpeoplewhodie.”Male,19years,student,Girishkdistrict,Helmandprovince

Although the precise figure is disputed, it isclearthat therehasbeenanalarmingupsurgeinciviliancasualties,asthewarhasworsened.Since2009, violencehasbeenon the increase,with2013providingarecentandstarkexampleof its impact on civilians. According to the UN,civilian casualties increased by 14% in 2013comparedtothepreviousyear.18Theyearsawthehighestcombinedfigurefordeathsandinjuriesofcivilianssince2009.2013wasalsotheworstyear since 2009 for women and children, withan increaseof34%oftheirdeathsand injurieswhencomparedto2012.19

TheDecember2013declarationbyBritishPrimeMinisterDavidCameronhailing“missionaccom-plished”20forBritishtroops,andproclaimingthata“basiclevelofsecurity”hadbeenachievedinAf-ghanistan,isalsoarecentexampleofthegapingchasmbetweenrhetoricandreality.Thispoliticallyexpedientdiscourseisatcompleteoddswithwhatso many Afghans actually experienced in 2013 –risingviolenceandinsecurity.

An estimated 630,000 people are internallydisplaced in Afghanistan, with 124,000 of themnewlydisplacedin2013alone.21Inaddition,some2.6 million Afghans are currently refugees inneighbouringcountries,with1.6millionoftheminPakistan.22OCHAestimatesthatin2014morethanhalfamillionpeopleinAfghanistanwillneedemergencyshelterandnon-foodassistance.23

Ontopofdeath,injuryanddisplacementduetocon-flict,Afghansmustcontendwithpoverty,foodinse-curity,malnutritionanddisease.It’sestimatedthatoneintenchildrendiesbeforetheageoffive,mainlyfrompreventablediseases.24Nationalstatisticsalsorevealthatastaggering36%ofthepopulationcan-notmeettheirbasicrequirementssuchasaccesstofood,cleanwater,clothingandshelter.25

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THE POLITICS OF AID IN wArThroughout much of the war, the biggestinternational donor countries – which are alsobelligerents – have directed the bulk of aid inlinewiththeir‘stabilisation’objectives,througha counter-insurgency strategy (COIN). Donorshave transformed aid dollars into a form ofammunition in their quest to defeat the armedopposition.Byusingaidasamilitarytool,donorshave often failed to adequately prioritise helpfor the most vulnerable first, provide effectiveassistanceorplacebeneficiaries’interestsovertheirownpoliticalandmilitaryones.

Foreign military commanders, wedded to COIN’sdoctrinal framework to “clear, hold and build”26conflict-areas, were given the power to directbillions of dollars into development projectsthrough Provincial Reconstruction Teams (PRTs),ortodeliveraiddirectlythemselves.Forinstance,about US$1.5 billion in US-military controlledCommander’s Emergency Response Program(CERP) funds were spent from 2004 to 2011.27Additionally,26PRTs,consistingofamixofmilitary,diplomatic,developmentandciviliancomponents,were tasked with providing the “build” in COINefforts.LinkedtoISAFandundermilitarycontrol,28PRTsweretodeliverpeacedividendsdesignedtowin ‘hearts and minds’, often in the form of so-calledQuickImpactProjects.

Aid provision thus became threat-based ratherthanneeds-based,withadisproportionatesharedirectedtowardsinsurgency-affectedareaswhereinternational troops were present, regardlessof whether this was where the greatest needswere to be found.29 Trust in the effectiveness ofaidwasalsoharmed. Itquickly transpired thatthemilitaryanddonorshad implicatedaidanditsprovidersintheconflictforveryquestionableresults.TheQuickImpactProjectswererapidlydubbed“quickimpact,quickcollapse”ventures,with various tales of expensive, unsustainablereconstruction projects that are now barelyfunctioning.30,31,32,33

Furthermore, military involvement in activitiestraditionally implemented by aid agenciesblurred the boundaries between both groups,with serious ongoing consequences for theperception of the neutrality and independenceofaid.This increasedtherisks foraidworkersoperating in an already insecure and volatileenvironment.34In2013,thenumberofaidworkers

killedinAfghanistanmorethantripled,35makingthe country the most quantitatively dangerousplaceintheworldforreliefwork.

Many non-governmental organisations (NGOs)wereseenaschoosingsidesinthewar,withAOGsviewingaidingeneralastoofaralignedwiththeobjectivesofonesideoftheconflict.36,37DangerousrhetoricbyinternationalforcesimplyingthataidNGOswerepartof the ‘softpower’effortsofanation-buildingproject,furthercompoundedthedamage.38Withsomeexceptions,alargenumberof international NGOs actively played a role inthe stabilisation agenda themselves, acceptingfundingearmarkedtoplaceswheretroopsfromtheirdonorcountriesweredeployed.Theytookan opportunistic approach, side-lining theirhumanitarian expertise and principles for thesakeofthedevelopmentfundingavailable.

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“Inourareathecanalsarehalf-finished;theschoolbuildings are half-finished; the clinics are half-finished.Thismeansthatsomefamilieshavetopayupto100Afsjusttogetonegallonofwater,becausethe half-finished canals don’t have the water weneed.Itmeansthatwedon’thaveproperhealthcarein our area. A lot of the doctors also escaped theplacebecauseofthefightingandinsecurity.Noonewantstocometoworkinourarea.”Male,25years,schoolprincipal,fromBaghlanprovince

Aprematureandpoliticallymotivateddefinitionofthecontextsince2003as‘post-conflict’suitedtheUS-ledcoalitionandtheAfghangovernmentit supported. Acknowledging the extent of thehumanitarian crisis did not. As part of theirstabilisation strategy, donors over-emphasisedsupport to systems building and strengtheningtoenhancethepopularlegitimacyoftheAfghangovernmentasaserviceproviderforitspeople.While supporting systems is essential work, itshould not come at the expense of respondingtotheimmediateneedscreatedbytheconflict.Reliefaidhasrepresentedonlyafractionofthetotal official development assistance providedto Afghanistan. Despite the large amounts ofaidpledgedtoAfghanistansince2001–around$90 billion39 – humanitarian financing makesup less than 7% of non-security internationalassistance.40

The ramifications of how aid was politicisedcontinue to impact the population’s accessto assistance today, including healthcare.Political priorities are still too often placedahead of addressing needs, as illustratedby the Government of Afghanistan’s recentannouncement that some health facilities andschoolswillbeusedasregistrationcentresandpollingstationsforthe2014elections.Withthecurrent political process strongly contested byAOGs, voting centres are at high risk of beingattacked,aswasthecaseinpreviouselections.41Thisputspatientsandthestaffworkinginthesehealth centres at increased risk, ultimatelymaking itdangerousforpatientstoreceivethecaretheyneed.

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SELECTIvE STOrYTELLING AND THE HEALTH SYSTEMUsing selectively chosen data to emphasiseprogress, health has regularly been held upas one of the “best performing reconstructionareas”42 inthecountry,andevenhailedas“thebest thing the US did in Afghanistan.”43 Suchexuberant claims jar with MSF’s research withpatients about their access to healthcare andwithwhatMSFteamswitnessonthegroundinthe four provinces where they run or supporthospitals.Theofficialdiscoursetoooftenshroudsthecomplexrealityontheground,glossingoverthe flaws of a health system overly-orientedtowardsa‘post-conflict’approachwhosedesignfrequentlyfailstomeetpatients’needs.

When the ‘reconstruction’ project began in Af-ghanistanmorethanadecadeago,unregulatedprivatehealthcareprovisiondominatedthemar-ket.44,45 The public health system barely func-tioned, with at least 70% of the limited healthservices provided by NGOs.46 As part of recon-struction, the political imperative was to pro-videbasichealthservicesasquicklyaspossible.Contractingouttonon-stateproviders,suchasNGOs,wasproposedasthewaytodothis.

In2003,theMoPHanddonors–namelytheWorldBank, USAID and the European Commission –introducedtheBasicPackageofHealthServices(BPHS),tobeimplementedthroughcontractingservices out to both international and AfghanNGOs.Secondarylevelservices–abovedistricthospital level,which is included in theBPHS–were developed in 2005. Called the EssentialPackage of Hospital Services (EPHS), it wascreated to improve and define the secondaryservices for provincial and later regionalhospitals.47

There has been significant investment in thehealth system since then. In a 2013 survey48half of those interviewed across the countryexpressedsatisfactionwithclinicsandhospitals(52%) and half (50%) with medicines availablein their local area. Between 2002 and 2010there was an estimated tenfold increase inannual disbursements of official developmentassistanceforhealth.49However,itisthepatientsusing the system who continue to finance thebulk of health expenditure, with out-of-pocketexpenses from Afghan households accountingfor83%ofallhealthexpenditurein2010.50

The BPHS contracts are now the foundation oftheAfghanhealthsystem.Mostreportsindicatethat they have allowed basic health services tobescaledupinthecountry,whichwasimportantandnecessary.51Coverageassessmentsshowingthe spread of health centres indicate progress;however,theactualextentofservicecoveragehasbeen questioned. There are recurring problemswith the availability of medicines, basic qualityindicators and adequate (especially female)staffing,whiletherearecontinuinghighlevelsofout-of-pocketcostsforpatients.52,53,54,55,56

HealthstatisticsfromAfghanistanarenotoriouslyunreliable. Constraints in monitoring – causedin particular by the remote control support ofhealthfacilities–meanthatdatafromthemostinsecureareasareoftenexcludedfromstatistics.Thisintroducesapersistentbiasthatislikelytocontribute to overly positive country averages.Contradictory household assessments,57 thelackofindependentcrosschecks,andreportsbyforeignconsultantswhooftendonotleaveKabuland reproduce data provided to them withoutmonitoring for accuracy, all raise seriousquestionsaboutdatareporting.

In 2011, the World Health Organization (WHO)estimatedalifeexpectancyatbirthof60years,a maternal mortality ratio of 460 per 100,000livebirths,andanunder-fivemortalityratioof101 per 1,000 live births.58 While such generalhealth data indicate an improvement since2002, nevertheless mortality rates remainconsistentlyandsubstantiallyworsethanothercountriesintheregion.Inaddition,theproblemsencounteredwheninterpretingthecoverageoftheBPHSalsooccurwheninterpretinggeneralhealth data from Afghanistan, as populationestimates are unreliable and most data arebased on modelling. For instance, whenmortalityestimateswereadjustedforexpectedreportingbiases,theunder-fivemortalityratiodoubled,jumpingto209per1,000livebirths.59

Claims that 85% of people in the country nowhave access to healthcare compared to 9%in 2001 are repeatedly trotted out.60 This isdespite limitations in the assessments forsuchstatistics,withsomeareasnotadequatelyincluded,particularlyruralorremoteareasandthoseinthesouthernregion.61,62,63

Such positive claims are also at odds withresearch conducted for the InternationalCommittee of the Red Cross (ICRC) in 2009,which estimated that more than half thepopulation had little or no access to basicservices, including healthcare.64 Additionally,in2013,inacountrywidesurvey,whenaskedtoidentifythebiggestproblemsfacingAfghanistanat the local level,healthcarewascited 13%ofthetime.65

Reconstructionofthehealthsystemhaslargelybeen intended to demonstrate the benefits ofthe international military intervention and thecapacities of the newly established Afghangovernment. The story about healthcare risksbeingskewedbythepersistenteffortsofdonors,theinternationalcommunityandthegovernmenttoshowpeacedividends.Itispredictedthatthenumber of people in need of access to healthservices in Afghanistan will increase from 3.3to 5.4 million in 2014.66 If the health system isunabletomeetthoseneeds, thestakesfortheAfghanpopulationwillbeextremelyhigh.

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ThestatisticsandstoriesfromMSF’sresearchoversixmonthsin2013withhundredsofpatientsinKunduz, Kabul, Khost and Helmand provinces make it clear that prevailing success stories abouthealthcareprovisionoftenmasktheseverityofthebarriersthatimpedeaccesstoaffordable,qualitymedicalassistancefortoomanyAfghans.

People’sperceptionsandexperiencesofthehealthsystemprovideinsightintothemultiplebarriersthatcanhinderorpreventaccesstohealthcareinthefourlocations. InterviewsalsounderlinethatthereisnohomogenousrealityforpeopleacrossAfghanistan.Barrierstoaccesstohealthcarevaryacrossprovinces,andsotoodoestheirimpact.Evenwithindifferentdistrictsofthesameprovince,theobstaclespeoplefacecanvarydependingonawiderangeoffactors.

However,whilethedegreeofproblemsmaydifferfromdistricttodistrictorprovincetoprovince,thereareclearcommonalitiesacrossthefourlocations,particularlyintermsoftheheavyimpactthewarhasonhealthandondelayingorpreventingaccesstohealthcare.

BARRIERSTOACCESSTOHEALTHCARE

wAr AND INSECurITYThe conflict creates dramatic barriers thatpeople must overcome to reach basic or life-savingmedicalassistance.Italsodirectlycausesdeath, injuryorsufferingthat increasemedicalneeds.Ineachofthefourlocations,atleastoneinfivepeoplehadeitherbeenavictimofviolencethemselves within the last 12 months, or knewsomeoneintheirfamilyorvillagewhohaddiedasaresultofviolence.ThiswasashighasoneinthreepeopleinKhost,whereaquarterofallthoseinterviewedknewsomeonewhohaddiedas a result of that violence, the vast majority(86%) as a result of the armed conflict. In alllocations the ongoing war was the main causeofviolentdeathoverthepastyear,withciviliansrepeatedlycaughtupindirectattacks,crossfire,bombingsorlandmineexplosions.

“This latest pregnancy was different,because of the conflict. The baby diedinsideheralmostthreeweeksago.Iamheretodaytofindoutifmywifeisokayandwhathappened.Therewasabomboutsideourneighbour’sgate,andwhenitexplodedmywife lostourbaby.AndthereisnothingIcandoaboutthis.It’snot normal, but in a way it is normal,becauseweareusedtoallthisviolence.Butitisnolife.Wejustexist,survivingtheinsecurity–whichisthemotherofallourproblems.”Male,50years,farmer,fromTagabdistrict,Kapisaprovince

TABLE 1: Experience of violence within the last 12 months

Did you, your family, or a neighbour suffer from violence? Helmand n=179

Kabuln=199

Khostn=183

Kunduzn=189

Yes 28.5% 23.1% 34.4% 30.2%

violence resulting in death of family or neighbour

Yes 23% 21% 27% 19%

Cause of violence, as percentage of all violence suffered

Thearmedconflict 92% 79% 83% 86%

Other–criminalityorpersonalfeudsorunspecified 8% 21% 17% 14%

FIGURE 1: Type of violence experienced within last 12 months by family or neighbours of 131 patients

Helmand

(n=41) Khost

(n=26)Kabul

(n=38) Kunduz

(n=26)

Attack (fighting or crossfire)

Bomb (aerial, ground, rockets)

Landmine

Other (criminality, personal feud, unspecified)

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

22

46

3854

57

16

8

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21

13

32

17

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25

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TABLE 2: People displaced inside Afghanistan since 2001

Displaced in Afghanistan since 2001 Helmandn = 179

Kabuln = 200

Khostn = 193

Kunduzn = 189

Yes 46% 37% 14% 12%

reason why they were displaced

Conflictandviolence 82% 31% 26% 57%

Other(naturaldisaster/work/nomadic) 18% 69% 74% 43%

During the2013fightingseason, thepercentageof patients treated in MSF’s trauma centre inKunduz for war-related wounds, as opposed toaccidentalinjuries,increasedto13%betweenJulyand September, from 9% in the previous threemonths.Thisrisewasadirectresultofthehighlevelofviolentincidentsintheregion,thoughitcanalsobelinkedtogreaterawarenessofthetraumacentreamong thepopulation.During thatsametime,up to9%ofpatientsMSFadmittedhad tobereferredtootherhospitals,primarilybecausethetraumacentrehadreachedfullcapacityandhadnomoreavailablebeds.Inresponse,MSFisincreasingthenumberofbedsforinjuredpatientsfrom62to92overthenextyear.

The violence also leads to displacement, aspeopleseekrefugeelsewhere, increasing theirrisk of deteriorating health. In Helmand morethan one in three people had been displacedbyviolencesincetheUS-ledNATO interventionbegan in 2001. The majority of them had beendisplacedsince2009,with justoveroneinfourpeople (26%) forced toflee theirhomesdue toconflictsincethen.

“WearefromWardakprovinceandcameheretoKabulbecauseoftheconflictandviolence.WestillhavesomerelativesinWardakwhodidn’tflee.Thereisstillalotoffightingbetweenthegovernmentandtheoppositiongroupsback there. If the fighting stops one day, then I will go back to Wardak,whereIwasborn.TherearealotmoretreesandgreenpasturestherethanhereinKabul.Butwewon’tgobackuntilthefightingends.”Female,36years,fromWardakprovince,livinginDistrict12,Kabul

“Last year one of my brotherswas taking a patient from Nawzad[district]tothehospitalinLashkarGah.Therewasaterriblebombontheroad.Threepeoplewereinthecar - my brother, the patient andthepatient’srelative.Theyalldied.”Male,22years,farmer,fromNawzaddistrict,Helmandprovince

TABLE 3: Death in family due to lack of access to healthcare in last 12 months

Did anyone in your family or close friends die due to lack of access to healthcare within the last year?

Helmandn=179

Kabuln=198

Khostn=189

Kunduzn=188

Yes 16% 13% 26% 19%

reasons for lack of access to healthcare and subsequent death. n =28 n =25 n =49 n =39

Conflictbarrier:Fighting,insecurity,nonighttravel 32% 8% 14% 21%

Financialbarrier:Cost 18% 28% 57% 13%

Distancebarrier:Proximity 11% 20% 19% 33%

Availabilitybarrier:No/inadequatehealthcare 25% 20% 2% 18%

Qualitybarrier:Poorqualitystaff,drugs,services 4% / 6% 5%

Culturalbarrier:Noonetoaccompany/nopermission 11% / / 5%

Other/Notspecified / 24% 2% 5%

Violence not only maims and kills directly, butalsoindirectly,byimpedingaccesstohealthcare.Significantnumbersofpeople ineach location,ashighasoneinfourinKhost,knewsomeonein their family or a close friend who had diedwithinthelastyearasaresultoflackofaccessto adequate healthcare. When not the mainreason, the conflict was always a major cause

of why now-deceased family members hadbeen unable to access adequate healthcare. InHelmand,people interviewedattributedalmostone in three (32%) of the deaths to conflict-relatedreasonspreventingsickorinjuredfamilymembersfromreachingmedicalcare,eitheratallorinenoughtimetosavetheirlives.

“In the last years, violence has blocked us coming to health centres andhospitalsmorethanahundredtimesIthink.Thereisconstantviolencearoundmy village. We never know how much fighting each week will bring. Thefightingdoesn’tstopwhenthereareinjuredpeople,sowecan’tgetthemtoadoctor.Sowewait,andthentheydie,andthefightingcontinues.Evenifyouareabletomovewithyourwoundedyoustillhavetogetthroughroadblocks,checkpoints,questioningandharassmentbeforeyoucanreachthehospital.”Male,25years,schoolprincipal,fromBaghlanprovince

FIGURE 2 : Reasons for death due to lack of access to healthcare during the last 12 months among friends or family of 141 respondents from 4 sites

Other

No man to accompany woman

Conflict

Distance

Cost

No car available

Poor quality of care

6%

18%

22%32%

14%

4% 4%

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For those who make it to a health facilitytheir journey is often fraught with danger anddifficulty.Inalllocations,asignificantpercentageof patients had faced problems reaching thehospitalwhereMSFworked–upto89%ofpeopleinKhost.Astaggeringfouroutoffivepeoplein

TABLE 4: Main obstacle faced on journey to MSF for current illness

Main obstacle faced on most recent journey to MSF Helmandn=149

Kabuln=79

Khostn=172

Kunduzn=127 TOTAL

Conflict 80% 9% 46% 59% 53%

Criminality 2% / 12% 8% 7%

Cost 2% 13% 23% / 10%

Distance 13% 62% 17% 32% 26%

Cultural 3% 14% / 1% 3%

Other / 2% 2% / 1%

“Thereisnodoctorinourvillage.Thereisnotransporttogetustoone,especiallyatnight,evenifwedaredtomovewithallthefightingandshelling.Ifwecouldfindacarwewouldputourselvesindangertobringtheseriouslyinjuredpeople.Butweusuallycan’tfindacar,sowedosomebasiccareourselvestohelpthemstayaliveuntilmorning.I’velearnedfirstaid,andothersinthevillagehavealsolearnedhowtocleanwoundsandputonbandages.Thisisallwecando,untilit’spossibletobringthewoundedtoahospital.“Male,48years,cookandfarmer,fromDasht-e-Archidistrict,Kunduzprovince

Helmand had experienced a conflict-relatedbarrier as their main obstacle to reach Boosthospital. Problems connected to the conflictwerealsothechiefdifficultiesinreachingMSF’strauma centre in Kunduz for three out of fiveinjuredpatients.

FIGURE 3: Proportion of 763 patients who experienced an obstacle on the journey to MSF

Helmand

(n=179) Khost

(n=194)Kabul

(n=201) Kunduz

(n=189) TOTAL

(n=763)

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

17

61

11

33 31

83

39

8967 69

Experienced obstacle

Did not experience obstacle

TABLE 5: Obstacles from insecurity to reach MSF over the last 12 months

Delays or blocks to access MSF from insecurity Helmandn=179

Kabuln=199

Khostn=192

Kunduzn=189

Yes 45% 8% 15% 45%

Type of insecurity mentioned that blocked or delayed access to MSF n=80 n=16 n=29 n=84

Activefightingorinsecurityfromconflict 59% 37% 35% 58%

Nonighttravel(duetoriskofviolenceorcriminality) 15% 44% 24% 25%

Landmines 11% / 17% /

Criminality 3% / 10% 12%

Roadblocksorcheckpoints 7% 13% / 5%

Other/notspecified 5% 6% 14% /

The problems they faced on their most recentjourney to a hospital where MSF works werenot isolated to that time of the year. Whenasked about difficulties created by insecurityto reach MSF over the preceding 12 months,a substantial number of people in Helmandand Kunduz had also experienced significantchallenges.Ondifferentoccasionsoverthelastyear,violenceandinsecurityhadeitherdelayedorstoppedmorethantwoinfivepeopleinboththoselocationsfromreachingthehospitalwhen

needed.Themaincausesofdelaysorblockagesacross all four projects were active fightingbetweenarmedgroupsandthe impossibilityofnighttravelduetoinsecurityontheroads.

Those who live in districts furthest away fromthe provincial capital are under-represented inthesampleofpeopleMSFinterviewed.However,of those interviewed, it was clear that theyfrequentlyfaceamoredifficultrealitythanthoselivingintheprovincialcapital.

FIGURE 4: Type of obstacle experienced on journey to MSF among 763 patients from 4 sites

Other

No night travelCheckpoint

Violence

No barrier

Criminality

CostDistance

CulturalConflict

Landmines

37%

31%

4%

7%

18%

2% 1%

11%

7%

3%

16%

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the longer journey to the hospital where MSFworks, but also because several districts inHelmand province experience frequent andintenseperiodsoffighting.

“Justeightmonthsago,whenIwascoming back home to our villagefromseeingthedoctorinthecentreofGirishkdistrict,thievesstoppedusandstoleeverything–thetyresfrom our car, the money in myhusband’spocket,hisphone.We’renottheonlyonesthishappensto.Theroadsaredangerous.”Female,22years,fromGirishkdistrict,Helmandprovince

Whilenotassignificantabarrierasthearmedconflict, criminality also poses persistentproblems for people on their journey to MSF.Though rarely cited on its own as the mainproblem they encountered, criminality wasoftenincludedintheexplanationofwhypeoplepicked the inability to travel at night as theirmain barrier. Additionally, at least one in 20peopleineachlocationmentionedthievesandbanditsaspartofalistingofmultipleproblemstheyhadtocontendwithwhentraveling.

“Criminality is increasing day byday. We don’t know which groupstheybelongtoalwaysbutcriminalsaredefinitelyontherise.Toomanypeople have been armed. Thosewho have weapons are the onescreating all the insecurity. Thereare lots of groups with lots ofdifferentinterestsinthisarea.Andthosewhowant todestabilise thesituation here just give weaponsto militias, to criminals, andeverythinggetsworse.”Male,30years,farmer,fromImamSahibdistrict,Kunduzprovince

“There is nothing the communitycando.Wearecaughtbetweenbothsides.Andsowepicksides.Halfofussupport thegovernment,halfofussupport theTaliban.Themiddlepeoplewillnotsurvive.Youhavetopickasideoryouwillbethefirsttosufferandyouwillnothaveanyonetohelpyou.Thepeopleinthemiddleareindangerfrombothsides”.Male,48years,cookandfarmer,fromDasht-e-Archidistrict,Kunduzprovince

While official Afghan sources claim that theAOGshavejustfiveofthe416districtcentresinAfghanistanundertheirpermanentcontrol,thisstatistic ignores the reality of life outside theimmediate district centre, where governmentcontrolhaslessreach.67Thoseintheperipheralareasaremorelikelytobetrappedbetweentheinexorablepressuresof the insurgencyandtheinternationalornationalmilitaryforces.Thisinturnmakes itmoredifficult forthemtoaccesshealthcare.

“Where I live has too manyexplosions and attacks. Thecommunity begs the Taliban notto fight from our village, becauseafter the government side comestopunishus,but theydon’t listen.We’resotiredofallofthekillings,theviolenceandthefear.”Male,48years,farmer,Sabaridistrict,Khostprovince

In Helmand, those interviewed from LashkarGah, the provincial capital, were considerablyless likely to cite the threat of violence as abarrier to reaching the hospital, than thoseliving in other districts. All the people fromMusa Qala, a northern district of Helmandprovince, cited violence as the main barrierto reach MSF – a rate of six times more thanthose already living in Lashkar Gah district.The higher threat of violence for those livingoutsidetheprovincialcapitalisduenotonlyto

women,babiesandinjuredciviliansdonotsur-vivethewait–eitherdyingduringthenight,onthe journey the next day, or shortly after theyreachthemedicalfacility.

“It is too dangerous to go out atnight. So we can’t bring someonetothedoctoronceit’sdark,eveniftheir sickness or injury is serious.Wecan’tmoveatnightorallofuswouldbekilledontheroad.So,weprefer that they die quickly ratherthan having to suffer through thenightonlytodiethenextdayorontheway.Thisisourreality.”Male,50years,farmer,fromTagabdistrict,Kapisaprovince

Furthermore, the current conflict impacts theability and willingness of healthcare providersto work in the most insecure areas. Patientsfrequentlyspokeofmedicalstaffandambulancedriverswhoweretooafraidtotraveltothemostinsecurezones.Thisisespeciallytrueforfemalehealth workers. Many patients spoke of no-goareas forgovernmenthealthworkersandevenprivatedoctors,resultinginentirecommunitiesbeingleftwithoutaccesstoessentialhealthcare.

As well as causing fear for health workers, theconflictcontinuestotakeaserioustollonpeople’smentalhealth,68withestimatesofupto60%ofthepopulation,mostlywomen,sufferingfrompsycho-socialproblemsormentalhealthdisorders.69

“Ihad14children,andIlosthalfofthem.They were killed during the conflicts.I lost four boys, three daughters, and ahusband.Theyweretooyoungtodie.Somany of my people have died from thewarshere…Wearescared.Myheartandheadarefullofthoughts.Sometimesmyheart gets so heavy that I have to findsomeone to talk to so I can try to clearitout,clearoutmylife.Itrytolaughformy family because I must stay sane forthem.IlaughtoforgetorIwouldgocrazywithallthedeaths.”Female,44years,fromKunduzdistrict,Kunduzprovince

Therearecomplexsetsofreasonswhypeopledelay seeking medical help, including a lackof awareness about illnesses, symptomsand available treatments; lack of transport;and lack of money. However, the threat ofviolence, insecurity and criminality en routecanalsoresult inpeopledelayingthetriptoahealthfacilityuntiltheirmedicalconditionhasdeteriorated to the point of endangering theirhealthorevenlives.

In Kunduz more than one in five people (23%)had been forced to wait more than 12 hoursbeforefirstseekingmedicaltreatmentfortheirinjury.InHelmandclosetohalf(46%)ofpatientsinterviewedhadwaitedmorethanaweekbeforeseekingcarefortheircondition,whileoveroneinfive(22%)ofthemhadwaitedmorethantwoweeks. In both Helmand and Kabul, 60% ofpeople with a malnourished child presentedfor medical care more than one month aftersymptoms first began. In both locations, fourout of five people (79%) with fever had waitedmorethanaweekbeforeseekingtreatment.

For some patients, hours can mean thedifference between life and death. Traumapatients with serious injuries usually need toarrivewithina‘goldenperiod’–onehourafterthe incident – for a surgical intervention thatwillpreventtheirdeath.Thechancesofsurvivalforpregnantwomenwithpostpartumbleedingafter a difficult delivery at home decreasedramatically if they do not arrive at a healthfacilitywithintwohours.

“A few months ago a woman in myvillagewaspregnant.Shehadprob-lemsandneededtogettoahospitaltodeliver.Therewasfightingatnightso we couldn’t bring her here. Sheandherbabydiedthatnight.”Female,28years,fromBakdistrict,Khostprovince

The inability to travelatnightdueto insecurityhas particularly severe consequences for seri-ously injured people or women in complicatedlabour. Families are forced to hold ‘death-watches’overtheirsickorwoundedlovedonesthroughout the night, hoping they will surviveuntil morning when it might be safer to reachadoctor.Patientsreportedthatmanypregnant

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than an hour by vehicle to reach the hospital.Morethanoneintenhadtravelledovertwohoursbymotortransport.

Patients in both Kabul and Kunduz citeddistanceasthemainobstacletoreachingMSF.AlmostonethirdofthoseinterviewedinKunduzexplained that the long distance to the traumacentre had been a significant difficulty whentrying tobringwoundedpatients toemergencycare. Before MSF opened the trauma centrein 2011, people suffering from severe injurieswereforcedtomaketheevenlongerandmoredangerous journey to Kabul or Pakistan – orvisit expensive private clinics – to receivetreatment.Consequently, fewpatientsobtainedthe specialised care they required, resulting indebilitatinginjuryoravoidabledeath.

Last year, one fifth of all the injured patientstreated in the trauma centre had travelledfrom provinces outside Kunduz province. Yet,despite the presence of the centre – still theonly specialised surgical centre of its kind inthe northern region – the journey for limb- orlife-savingcareinthenorthremainsimpossiblefor too many. People interviewed in Kunduzfrequentlyspokeofseriouslywoundedciviliansin their communities who had been unable toreachMSF’straumacentre.

“Whereweliveistoofarawayfromclinics for injured people to reachthemontimetosavetheirlives.Thereisnopropersystemtotreatpeoplewhile they are being transferred toaclinic.There isnoambulance,nodoctorstogowiththem.So,bythetime you finally reach a clinic, theperson is already dead. They diefromtheirinjuriesontheway.”Male,25years,student,fromIshkashimdistrict,Badhakshanprovince

DISTANCE

Today,57.4%oftheAfghanpopulationliveswithinone hour’s walking distance of a public healthfacility,accordingtonationalstatistics.70Thisisadramaticincreasefromonly9%in2001.71Indeed,in the four locations the majority of those MSFinterviewed said that there was some form ofhealth facility, whether public or private, withinan hour’s travel of their homes. However, withurbanisationpushingmorepeopletowardstownsandcities,figuresshowingthatmorepeoplenowliveclosertothemaretobeexpected.72

A health centre that exists is not the same asone that is used or that actually functions wellin practice. Thus, the proximity of a physicalstructureonitsownisnotenoughtoguaranteeaccesstohealthcare.Theavailability,accessibilityand acceptance of the services are also criticalfactors in determining the utility and usage ofhealth structures for a community. Turning abuildingintoafunctioninghealthfacilityrequiresconsistent presence of qualified staff, regularsupplies of quality drugs, and the possibility toreachandusethecentresafelyandsecurely.

In all four locations the majority of thoseinterviewedhadnotgonetotheirclosestpublichealthfacilityduringarecentepisodeofillnessin their household. In Helmand and Khost, asmany as eight or nine out of every ten peoplehadnotusedthepublicsystem,despitethefactthat it promises free care. They avoided theirnearestpublicclinicorhealthpostforavarietyofreasons,mostlylinkedtonegativeperceptionsof both the quality and availability of staff,treatmentsorservicesonoffer.

Thismeansthatpeopletravel further,oftenfarmorethananhour’swalk,toobtainthehealthcaretheyneed,increasingbothcostsandrisksduringthejourney.Onequarterofthewar-woundedandseriouslyinjuredpatientsinKunduzhadtravelledbetweentwoandsixhoursbycarbeforereachingthe hospital. Of those interviewed in Helmand,two out of every five (44%) had travelled more

“Thepublicclinicsarealltoofarawayfromus,becausenoonewantstorisk working here. I don’t think there are any public clinics in our area.Maybethegovernmentbuiltsomesomewhere,butIhaven’tseenanywithmyeyesandIhaven’theardofthemwithmyears.”Male,55years,farmer,MusaQaladistrict,Helmandprovince

An absence, or a perception of the lack, oftreatments and services for their conditionssometimes even pushes people to seek care inothercountries.InKabuloneinfive(21.6%)peoplehadtravelledoutsidethecountrytoseekthecarethey required, the vast majority of them (90%)headingtoPakistan.InKunduzandKhost,almostoneinten(9.6%)andonein12people,respectively,had gone to Pakistan to seek treatment for anillness of someone in their household in theprecedingthreemonths.

“Wedon’twanttohavetotravelthisfar. If there was decent healthcarenear us, believe me, we wouldn’tcomehere. In thedistricts,you findsimpleshopkeepersdistributingthedrugs,drugsthatharmyou.Wedon’thavethequalifiedstaffandwedon’thave the proper clinics. So, peopleareforcedtotravelasfarasLashkarGahandtakealltherisks.”MaleShurafocusgroupmember,fromLashkarGahdistrict,Helmandprovince

Thelongdistancespeoplemusttraveltoseekcarenot only delay the provision of urgently neededtreatment,butalsoforcethemtoundergoperilousandcostlyjourneys.Duetoinsecurity,peopleriskfurther injury and even death on the journey asthey struggle with violence, criminals, crossfire,landmines,checkpointsandroadblocks.

“A few months ago [August 2013]my pregnant cousin came to MSF[maternity hospital] to deliver herbaby, accompanied by three of ourmalerelatives.Onthewayhometheywereallsohappybecauseofthenewbaby.Theircarhitalandmineinourdistrict.Everyoneofthemdied.”Female,23years,fromSabaridistrict,Khostprovince

The insecuritymeans thatpeopleoftenprefer totravel to medical care in large groups, seekingprotectioninnumbers.

FIGURE 5: Proportion of patients that used the closest public health facility during previous illness

Helmand

(n=178) Khost

(n=193)Kabul

(n=196) Kunduz

(n=187)

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

YesYes

Yes

Yes

NoNo

No

No

“We live in the mountains inSamangan province. It’s far awayfromhere[Kunduzcity].Ittookusmore than half a day to get here.Wewalked,travelledbydonkeyandthentookataxi,butthemajorityofthejourneywasonfoot.Myrelativecouldn’t afford [the transport] tobring his injured son here. So Iborrowed the money from peopleI knew and travelled with himinstead.Topayback themoney, Iwillhave tosellmanymorenuts.Andourfamilywillhavetoeatless.Thereisnootherway.”Male,43years,farmer,KhuramWaSarbaghdistrict,Samanganprovince

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“WhenthefightingstartsaroundustheroadstoLashkarGahareblocked.So we can’t get to the hospitalshere.Nooneisallowedtopass.Themost serious patients try to get toPakistan,buttheyneedlotsofmoneyfor that.Thebiggestproblem is thepregnant women without money –when security conditions are badthosewomenwhocan’taffordtogettoPakistandie.ForthosewhohavethemoneyforPakistan, the journeyis also dangerous. They must dealwithalotofharassmentfromthievesandcriminalsontheway.”Male,38,Farmer,GarmsherDistrict,Helmandprovince

“Sixofushadtotravelherebecausetheroads are dangerous at night, and weneedlotsofpeoplewithustobesafe.On the way we were checked by theinsurgentsthreetimesandbyapolicecommander another time. We onlyarrivedatyourhospitalwithourinjuredthree hours later. It should normallytakejustonehourand30minutestogetherefromwherewelive,butwithallthecheckpointsittookdoublethat.”Male,30,farmer,Dasht-e-Archidistrict,Kunduzprovince

Thedistanceisevenmoreofaproblemduringthewinter:

“Whenoneofourpeopleistoosickwithafever,wehavetotrytogethimto the hospital quickly. So we carryhiminourarmsandthenwegobydonkey.Thenwejusthopethathecanlastthejourney.Alotofchildrendieonthewaybeforewereachthehospital.Especially in thewinter,whenmostofthefeversicknessesoccurandthesnowmakesitimpossibletopass.Forfourmonthswehavesnowandthenit’stoodifficulttogettoanyhospitals.Itcantakebetweentenand11hoursandthepatientcandieontheway.”Male,43years,farmer,KhuramWaSarbaghdistrict,Samanganprovince

InAfghanistan,distanceisacompositebarrier:thelongerpeoplehavetotraveltoaccesshealthcare,the greater the risk that they will encounteradditionalbarriersontheway.Eachextramomenton the road potentially exposes them to moredirector indirect violence,pushes up the costofthejourneys,anddelaysthemobtainingthecaretheyneed.

Among the people MSF interviewed, at least 60%lived on less than US$1 per person per day, withhalfofpatientsinHelmandandKabullivingontheequivalentofjustUS$0.60orless.Eventhiscanbean underestimation of poverty levels for the mostvulnerablepeopleinthoselocations,asthoseunableto find the means to reach the MSF-supportedhospitals might be excluded from the survey.Additionally,MSFprojectsarelocatedinurbanareasand receive fewer patients from the rural areas,wherepeoplegenerallyhavelesswealth.

AccordingtotheWorldBank,morethanonethirdofpeopleinAfghanistanlivebelowthenationalpoverty lineof lessthanUS$1.25perday,73andas much as half the population is at high riskof impoverishment.74 Additionally, there areimportantdifferencesbetweenruralandurbanareas,with25%ofruralcomparedtoonly2%ofurban populations categorised as living in thepoorestfifthofthepopulation.75

COSTS

“Thereisnothingwecando.Wearethepoorpeople.Theywilldestroyuswiththeirfighting.”Male,30,farmer,Dasht-e-Archidistrict,Kunduzprovince

TABLE 6: Household expenditure per day per person as reported.

InUSDequivalent Helmand Kabul Khost Kunduz

Median(50%ofpeopleliveonlessthanthisamount) $0.6 $0.6 $1.2 $0.8

75%ofpeopleliveonlessthan $0.9 $1.1 $1.7 $1.3

% of people living on less than $1 per person per day 80% 71% 40% 61%

A significant proportion of the populationstruggles to make ends meet, let alone payfor healthcare. Among the people surveyed, atleast half described their household economicsituation as poor, very poor or extremely poor– all categories that meant they had problemsto pay for healthcare. In Helmand and Khost,asmanyasthreeinfourpeopledescribedtheirhouseholdaspoororverypoor.Theintervieweesin Kabul had the biggest category of very toextremely poor, with one in five people (21.2%)describingthemselvesassuch.

“InJanuary[2013],mynephewwassick. He had terrible diarrhoea.Weweretoopoortobringhimtoadoctor.Hewasninemonthsoldandhedied.”Female,25years,fromKhostMatundistrict,Khostprovince

Extremely poor = begging, no home; very poor = thereis sometimes not enough food available. Face seriousproblemspayingforhealthcareandschool; Poor=enoughmoney for food, but face problems paying for healthcare;Moderate = enough money for food, healthcare, school;Good=enoughmoney,evenforsomeluxuries.

FIGURE 6: Household economic situation as described by 759 respondents

Helmand

(n=179) Khost

(n=193)Kabul

(n=198) Kunduz

(n=189)

0%

10%

20%

30%

40%

50%

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70%

80%

90%

100%

821 18 11

65 4260

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25 3521

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“I’vealreadypaidsomuchtohelpmydaughter.NowI’verunoutofmoney.I spent it all on private doctors ortravelling to them. We came here[to Boost Hospital] because it’sfree.Yetwhenshewasdischargedweneededtostayhereinthetown,near the hospital, to bring her fordaily follow-up appointments. So,eventhoughthehealthcarehereisfree, itstill costsmoney forme tostayclosetoit.”Male,39years,mullah,Garmsherdistrict,Helmandprovince

However, even the poorest people often paidconsiderable amounts to try to meet theirhealthcare needs, either for direct medicalcosts, (doctors’ fees, drugs, hospitalisationor laboratory tests), or for other non-medicalcosts (transport toand fromthehealth facility,accommodation and food for relatives whoaccompanyahospitalisedpatient).

For a recent illness in the last three months,otherthantheonethattheywereinthehospitalforatthetimeoftheinterview,themediancostfor the total expenditure on healthcare wentfromUS$28 inHelmanduptoUS$68 inKabul.Such high totals for Kabul can be attributedto the fact that at least one in five people hadtravelledtoPakistantoseekhealthcarefortherecentillness.

TABLE 7: Total direct (medical and non-medical) costs incurred for a recent illness

(MedianandIQR*inequivalentUSD) Helmand Kabul Khost Kunduz All 4 sites

Direct medical costs 21 (IQR9-48)

55(IQR20-161)

23 (IQR12-45)

48 (IQR15-116)

32 (IQR12-84)

Direct non-medical costs 4 (IQR0-15)

14 (IQR4-38)

6 (IQR2-20)

5 (IQR1-34)

6 (IQR2-29)

Total costs 28 (IQR11-59)

72 (IQR25-223)

32 (IQR15-67)

63 (IQR19-145)

40 (IQR16-114)

Note: Thesearethemedianvaluesamongthosepeoplewhoreportedpayingthesetypesofcosts.Assomepeopledidnotrecallspecificdetailsofdirectandindirectexpenseswithinthetotalcostreported,thecombinationofmedianvaluesofdirectandindirectcostsreportedmightdifferfromthetotalcostsreported.Note:Directmedicalcosts=doctor,drugs,hospital,laboratory;Directnon-medicalcosts=transport,foodandaccommodationforthepeoplewhoaccompanyahospitalisedpatient.Note: IQr = the interquartile range, often called the ‘middle fifty’. It is the data between the upper quartile (Q3 or 75thpercentile)andthelowerquartile(Q1or25thpercentile).TheIQRuses50%ofthedata.Forexample,ifthemedianspentondrugswasUS$20thatwouldmeanthathalfthepeoplespend$20orlessondrugs,andhalfthepeoplespend$20ormoreondrugs.IftheaccompanyingIQRwas(10–50),thiswouldmeanthataquarterofthepeoplespend$10orlessondrugsand

anotherquarterspend$50ormoreondrugs.

TABLE 8: Selection of three expenses, medical and non-medical, incurred for a recent illness

(MedianandIQR*inequivalentUSD) Helmand Kabul Khost Kunduz

Drugs 21 (IQR10–48)

44(IQR26–151)

19(IQR10–38)

45(IQR17–99)

Doctors’ fees 4(IQR2–5)

7 (IQR4–12)

3 (IQR2–5)

5(IQR3–8)

Transport 6 (IQR2–20)

15(IQR4–38)

8(IQR3–19)

11(IQR4–36)

Medication consistently ranked as one of thehighest costs people incurred. In Kunduz andKabul, more than half of those interviewedhad paid more than US$44 on drugs during aprevious illness episode. Those who went toPakistanasthefirststepinseekingtreatmentacross all four locations paid a median ofUS$193onbothmedicalandnon-medicalcosts.Themajority,about60%,wasondrugs.Withaninterquartilerange(IQR)of116-341,oneinfourofthempaidmorethanUS$341.ThehighcostsofdrugscanbeattributedtothefactthatpeopleinPakistansoughtcarewithprivatedoctorsforchronicdiseasessuchascancer,hypertensionorhepatitis.

A non-medical cost such as transport isalso a significant drain on people’s financialresources. Ingeneral,themediancostrangedfrom US$6 to US$15 across the differentlocations. In each location one in four peoplepaidmorethanUS$19ontransporttoandfromhealthcare providers for an illness during theprecedingthreemonths.InKunduzandKabul,oneinfourpeoplehadpaidmorethanUS$35.ForthosewhowenttoPakistanasafirststep,thetransportationcostsusuallyaccountedforaquarteroftheirtotalexpenses(mediancostfortransportUS$48;IQR,29-90).

“Ifsomeoneissickatnightandtheydon’t own a car, they can’t move.It’s usually not possible to rent ataxiatnight,asthedriversaretooafraid to work. They are afraid ofthieves,theTaliban,thearmy,thepolice.Sopeopleare trappedandhavetowaituntilmorning.Duringthedaythecostoftransportis500PKR [US$5]. If you somehow finda car at night, then it’s 4000 PKR[US$38].”Male,19years,student,Girishkdistrict,Helmandprovince

In the most insecure areas, transport costsincreaseevenfurther,particularlyifpeoplefeelthe need to travel in groups for safety once itgetsdark.

“Ifwehaveapregnantwomanandwe need to get her to a maternitycentreinKunduztownit’snotalwayspossible. It’s too dangerous. But ifthepregnantwomanisintoomuchpain,andsomethingiswrong,thenwe will have to travel, even closeto night, to try to save her and thebaby. Then it’s like we’re going toa wedding ceremony there are somanyofusmovingtogether.Thereissafetyinnumbers,sowegoinabiggroup toescape thearmedmen. Iftheyseetoomanypeople,theydon’tattack.Butifthereisonlyoneortwoofus,thebanditswillgetus.”Male,25years,ImamSahibdistrict,Kunduzprovince

Considering the socio-economic status of thepatients, these are enormous sums of moneythat involve significant personal sacrifice tocover. Of all those who went to Pakistan fortheirfirst step,only35%wereable topay themedical and non-medical expenses with theirown savings; the remaining 65% had beenforcedtoborrowthemoneyorsellgoods.

In general, the amounts spent on seekinghealthcareinsideAfghanistanmakeadramaticcutintopeople’sfinances.76AnMSFassessmentof health facilities in Lashkar Gah, Helmand,in July 2013 found that a normal delivery forwomen at a private clinic ranged from US$90to US$150, with a caesarean section costingbetweenUS$200andUS$250,whichisbeyondthefinancialreachofmany.

Thecostsassociatedwithaccessinghealthcareforanillnessintheirhouseholdinthelastthreemonthspushedmanypatientsandtheirfamiliesinalllocationsintodebt,orforcedthemtoselltheirgoodsandassets.Theamountsvariedperlocation,withmorethanhalfofpeopleinKhostand half in Kabul engaging in some form of‘distressfinancing’tocoverthecostsofarecentillnessintheirhousehold.Evidently,thesearchforhealthcareinAfghanistanputsfartoomanyhouseholdsatseriousriskofimpoverishment.

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Even when medical services and treatmentsareprovided for free–as is thecase inall thehospitals where MSF works in Afghanistan –non-medical costs can be a serious barrier toseeking healthcare. The expense of getting tofreecarecanbeacriticalobstacletoovercomewhenmakingthedecisionaboutwhethertoseekcareorwheretodeliverababy.

“In my village a pregnant woman hadpains and needed to deliver. Her familydidn’t have the money to pay for trans-port to bring her here [MSF maternityhospital], or for a private female doctorcloser by. They rushed around trying tofind people to borrow money from. Bythetimetheyhadenoughmoneytomoveto here it was already late. On the way,bleedingstarted,fastandhard.Sheandherbabydiedbeforetheygothere.Thishappenstomanywomen.”Male,38years,teacher,fromJajiMaidandistrict,Khostprovince

For women who came to deliver in MSF’smaternityhospital inKhost, themediancostoftransport was US$9.6 (IQR 4.8 to 19.2). Threequarters of those interviewed in Khost had anaverageoflessthanUS$1.2tospendaday,andalmost 60% of the households had no savingsto pay the healthcare costs of the currentpregnancy.Thus, thecostof transport toreacheven free care would have been a significantburdentothesewomen.Itislikelythattherearemany other women across Khost province whosimply cannot come to the maternity hospitalduetoprohibitivetransportcosts,inadditiontoinsecurityontheroad.

For seriously injured people arriving in MSF’strauma centre in Kunduz, almost two in fivepeople(38%)hadpaidmorethanUS$6,withoneintenpeoplepayingmorethanUS$50,mostlyontransport costs. Up to now, security conditionsoutsidethedistrictcapitalhavemeantthatMSFhas not yet been in the position to run its ownambulanceserviceinthedistrictsoftheprovincein order to collect wounded people closer towheretheyareinjured.Atthesametime,clinicsin neighbouring districts or provinces do notyet have well-functioning referral systems andambulances.

“Inourvillagethereisnooneelseto buy our house, our lands, sohow could we get enough moneytogether in order to leave and getclosertoclinics?Wedon’thavethemoneytomovetothecity.Wedon’thave the money to even come tothe city. We need the governmentto put qualified doctors in clinicscloser to our homes to help solveourproblems.Weshouldn’thavetotravelsomanyhourstothecityandspend so much on traveling whentheroadsaredangerous.”Male,43years,farmer,KhuramWaSarbaghdistrict,Samanganprovince

FIGURE 7: Source of payment for healthcare costs among 721 respondents

Helmand

(n=169) Khost

(n=181)Kabul

(n=187) Kunduz

(n=184)

Savings

Borrowed

Sold goods

Other

0%

10%

20%

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5042

6568

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Whenpeopledidnotobtainthemedicationstheywere prescribed, the main reasons were thattheycouldnotafford it,or that thedrugswereunavailable in the health facility. Almost half(47%)inKunduztothreeoutoffive(60%)peopleinKabulfailedtogetthemedicationtheyneededbecauseoffinancialproblems.

“Whenwegotothe[publicfacility]the liquidsand injectionsare free.There is a pharmacy inside thehospital, but if you have to getthingsthere, thenyouhavetopay.Andsometimestheyjustdon’thavethedrugsinthehospitalpharmacy,sothenwehavetogooutsidetothemarketandbuythedrugsthere.”Female,41years,Kunduzdistrict,Kunduzprovince

Seventy-four of the seriously injured patientsinterviewed had been referred from anotherhealth facility to theMSFtraumacentreratherthan coming directly. The median cost theypaid was US$18, with one quarter of thempaying more than US$36. The lack of a fullyfunctioning referral system in the area causesdelays inreachingemergencymedicalcare forwar-woundedandinjuredpeople. Italsoforcespeopletospendmoneyontransportthatatleastone third of people interviewed in Kunduz didnothave.Thisisaseriousproblemforpatients,whichMSFwillneedtoaddress.

Consideringtheamountsthatpeopleareforcedto borrow, it is critical that healthcare centresensurefreecareisprovidedinreality.However,patients regularly reported that this was notalways thecase inmanyof thepublic facilitiesthey visited. Across all four locations, morethanhalf (56%)ofpatientswhovisitedapublicfacility ended up paying for all the medicationtheyneeded.Of thosepeople,27%paid for themedication inside the public facility itself, 60%purchased it in a private pharmacy, and 12%boughtitinthemarket.

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Ineverylocationthemajorityofpeoplehadnotvisitedtheirlocalpublicclinicatanystageduringarecent illness.Theirperceptionof thequalityof staff and services available in the facilitywas frequently the main deciding factor. Manypeople had major complaints about the qualityofbothprivateandpublicmedicalfacilitiesandpractitionersintheirareas.

In Helmand, three quarters of people wentto a private facility as their first step during arecent illness in their household. Only one infivewenttoapublichealthfacility.Ofthosewhowent to private facilities, more than half (57%)did so because they perceived that it was thebest quality. The second biggest reason (38%)wasbecause theprivatehealth facilitywas theclosestonetothem.

In Kunduz more than half (56%) of thoseinterviewedchosetogotoaprivatehealthcareprovider first, with just two out of five (38%)peoplechoosingapublicfacility.Again,ofthosewhowenttoprivate,themajority(64%)didsoastheydeemed it tobeofbetterquality,with thenext main reason (28%) being that the privatefacilitywasclosertothem.

People’sperceptionofqualitywasalsothemainreasontheyavoidedgoingtotheirclosestpublichealth facility. For at least one third of peopleinalllocations,apresumedlackofqualitywascited as the main reason they went to privatefacilities, rather than a closer public one. Ingeneral, people were most concerned andcritical about what they perceived as a lack ofappropriatedrugs,qualifiedstaff,waitingtimesandstaffconductinthepublichealthsystem.

GAPS IN THE HEALTH SYSTEMThe health system in Afghanistan is a work inprogress. Despite positive steps, significantgapsremaininthedeliveryofquality,affordablehealthcare, including for those in need ofemergency medical aid. There is substantialwork ahead to continue improving the healthsystemandtobetteradaptittotheneedsofthepopulation.

Violence, prohibitive costs and distance allconspiretodelayorpreventpeoplefromaccessingthe healthcare they need. Unfortunately, formanywhomanagetoovercomethosebarriers,upon reaching the health facility they reportthat they discover that it is closed, defunct, orprovides inadequate services. In this way, thecurrent health system, as it is, poses severalbarrierstoeffectiveaccesstohealthcare.

“Thereisnopropercareforinjuredpeople close to us. There are noproper facilities where we live. Inthe nearest hospitals and clinics[in Baghlan province] the doctorscan only give ‘spicy’ [poor quality]tablets. Those clinics don’t haveany dressings, no injections, justcounterfeittabletsinpackets.Whenourpeoplearebleeding,spicytabletswon’thelpthemsurvive.”Male,25years,fromBaghlanprovince

FIGURE 8: Main reason given for not going to the closest public health facility among 599 respondents from 4 sites

Other

Cost

PreferenceDistanceAvailabilityQuality

6%

42%

26%

13%

3%10%

“Inmyarea,there’sjustoneprivatedoctorandheusedtofixtyres.Hedidn’tstudymedicine,buthasonebigmedicalbookinPashto.WhenIwenttoseehimwithheadpainshetoldmetolookupthebookmyselfto find a treatment. That’s not adoctor! How can he treat anyonewhoisseriouslysick?”Male,22yearsold,farmer,Nawzaddistrict,Helmandprovince

The past reputation of the public healthsystem, coupled with patient preferences andassumptionsaboutpoorquality,maysometimeslead people to avoid their closest public clinic,evenif it isworkingwell.For instance,anMSFassessment of the public clinics in LashkarGah district in July 2013 showed that generalprimary healthcare provision in much of thedistrict appeared to be functioning well. At thetime of the visits, all the public health centreswere open and providing consultations free ofcharge and seemed to have adequate levels of

Long waiting times, combined with openinghours that do not always fit with the reality ofpeople’smedicalneeds,seemtopushpatientsawayfromthepublichealthsystem.

“The government clinic in ourarea is only open until 12pm. Soif we have a seriously injuredperson or a pregnant woman withcomplications,wecan’tgothereinthe afternoon. And we can’t travelatnight.Wehavetowaitforthenextdayuntiltheroadissecure.Mostofthepregnantwomenwhodiedosobecausetheycan’treachahospitalintimetosavethem.”Male,77years,LashkarGahdistrict,Helmandprovince

Issueswithstaffqualityandconductwerealsofrequentlycitedasasourceoffrustrationinbothprivateandpublicpractices.

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It is therefore essential that public healthfacilitiesofferqualitycareasanaccessibleandaffordablealternative.

“Beforecominghere,we’dgonetoprivate doctors about four times.Thepublicclinicsare too farawayfrom us. But the private doctorscouldn’t help. It was too serious.And they never suggested that wecome to another bigger hospitalfor help. They never referred usforward.They just toldus tocomebackagainandagaintothemeventhoughtheycouldn’tfixhim.”Male,55years,farmer,MusaQaladistrict,Helmandprovince

patientattendance.Duetosecurityconstraints,theassessmentwasnotcarriedoutintheotherdistricts of Helmand. MSF cannot, therefore,confirm the situation in the other districts ofthe province, including the rural areas, wherethereareusuallyfewerstaffandlessmonitoringcapacity, and where the population frequentlyspokeoffeelingunderserved.

Perceptionsarebydefinition,highlysubjective,and thus more difficult to quantify than issuesrelated to availability, since a service or astructure is either there or it is not. However,patient perception must not be discounted.Acrossallfourlocations,itisclearlyoneofthekeyinfluencingfactorsaboutwhetherpeoplewilluseaserviceornot.Additionally,itisclearfromtheir examples that there can often be seriousqualityproblemsintheirclosestpublicclinics.

Despite the fact that the BPHS has increasedcoverage by creating more health facilities inmore districts, the quality of what is availableinside the building remains of fundamentalconcern for people when choosing where toseek healthcare. This is especially pertinentconsidering that the BPHS has often beencriticised for prioritising quantity and coveragestrategiesoverquality,77and inspiteofseveraltoolsthatmonitorthequalityofservices.78

Whether the current levels of financing for theBPHS can realistically ensure the necessaryquality is regularlyquestioned.Particularly theexisting policy of awarding BPHS contracts forserviceprovisiontothelowestcostNGOprovider,with the risks that brings of undermining thequalityofservicesonoffer.79,80,81Wherequalityislow,orperceivedtobelow,communitydistrustinthepublicsystemwillonlyincrease,pushingthem further towards private providers, wheremanyspendmoneytheysimplydonothave.

The distrust of the public system is oftenaccompaniedbyamisplacedtrustintheprivatesystem.Enormouslypowerfulandunregulated,it too comes with its own set of problems intermsofqualityandcostforpatients.Medicineis a lucrative business for private providers inAfghanistan,andsomeelementsof theprivatemedical sector can be quite unscrupulous.While people regularly chose private as theoptionofquality,manyspokeofoverprescribing,misdiagnosing and even malpractice from thesideoftheprivatepractitionersthattheyvisited.

Inadditiontoquality,problemswiththeavaila-bilityofstaff,drugsandopeningtimeswereusu-allythesecondbiggestreasonpeoplebypassedtheirpublicclinic.OneintenpeopleinterviewedinKabulandHelmandcitedalackoftreatmentfor their particular condition as a reason whythey did so. In Kunduz, as many as two out ofevery five people believed their closest publicmedicalfacilitycouldnotassistthemwiththeirillness.Peopleinneedofmorespecialisedcare– includingwoundedpeople,womenwithcom-plicated pregnancies, malnourished childrenand people with chronic diseases – especiallyreportedfacingseriousdifficultiesfindingtreat-mentattheircloserpublicclinics.

ThosefromKabulandKunduzwhotravelledtoPakistan sought care mostly in private healthfacilities at great cost. They were in search oftreatments for conditions that they believedthe secondary and tertiary hospital system in

Afghanistanwasill-equippedtocaterfor,suchascancer,diabetes,kidneydisease,hypertension,heartdiseaseorhepatitis.

Evenfor injuriesdirectlyrelatedtotheconflict,thereisaworryinglackofservicesandfacilities.In2013,thenumberofpeopletreatedforweaponwounds rose by 60% in Afghanistan, while theneedfortraumacareinthecountryfarexceedsexistingcapacitytoprovideit.82

Peoplealsohighlightedthelackofaproperpublicreferralsystemtotransferwoundedpeopleandpregnant women from smaller health posts tohospitalsasanotherseriousgap.Thisincreasesthe distance, security and cost barriers theymustovercometoreachappropriatecare.

“Afterthefightingtherearealwayssix to 20 injured people who needmedicalhelp.But there’sonlyonegovernmenthospitalinthedistrict,withnoambulancesystemtocarrythewoundedandnooxygen.Whenwetakeourwoundedtothishospi-tal, they don’t have the treatmentthey need. They can’t help themenough, so then we have to try togettheinjuredpeopletothecentreof theprovinceoreventothenextprovince.Theyoftendieontheway.”Male,21years,fromLaghmanprovince,livinginDistrict12,Kabul

Thoughthepublicsystempromisesfreecare,inpracticepeoplerevealedthatthis isnotalwaysthe case, and they often had to pay for drugsand some doctors’ fees. In addition, there arealso other hidden charges and accusations ofcorruption.Inallfourlocations,peoplespokeofdoctorsinpublicclinicspushingpatientstotheirmore lucrative after-hours private practices.Peoplealsoregularlycomplainedofgovernmentclinicsinremoteareassellingdrugsuppliestothe local pharmacy so that patients could notfindthedrugsintheclinicandwerethenforcedtopayformedicineatthepharmacy.

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In2012,450healthfacilitiesclosed–temporarilyorpermanently–forreasonsofinsecurity;upby40% compared to 2011.84 With health providersalready unable to operate properly, eitherpermanently or temporarily, in 58 districts ofthe country,85 any further disruption will havegrave consequences. The announcement bythe Government of Afghanistan that somehealth facilities, along with schools, have beendesignated as registration centres and pollingstations for this year’s election is dangerous.Clinics must not be used as a platform for apolitical process or as tools to advance state-buildinggoals;theymustbesafelocationswheresickpeoplecangetthemedicalcaretheyneed.86

Withvotingcentresathighriskofbeingattacked,as was the case during the 2009 election, thisdecision could again place the lives of healthworkers and patients in direct danger. Safetyconcernscouldresultinpatientsavoidingthosehealthcentres,forcingthemtotravelfurthertoanother public or private clinic, increasing thedelays,costsandsecurityriskstheyendure.

A consequence of the insecurity is that manyhealthcentresaremanagedbyremotecontrol,andmonitoringreportscanbesubmittedwithoutthe facts being checked on the ground. In thisway, the conflict and violence not only blockthe population’s access to healthcare, but canalsofacilitatethecontinuationofbadpractices.Extrasupportfortheseremotefacilities,wherepatients reported the most striking problems,might increase further accountability towardsthecommunities theseclinicsserve,andavoidfurtherlossofcommunitytrustinAfghanistan’shealthsystem.

“There are public clinics in ourdistricts, but there are no medicalstaff and no medicines inside.We need people to monitor theseclinics.WeneedthegovernmentorNGOs to monitor them. Someoneneeds to monitor them, becausethe clinics in the districts don’twork. And most people know this,so they don’t go there, and theyspendalltheirmoneyonprivate,ortheytravelfar.”Male,57years,farmer,Marjahdistrict,Helmandprovince

LACK OF rESPECT FOr MEDICAL FACILITIES AND HEALTH wOrKErSAll warring parties, as well as an increasingnumberofcriminalgroups,continuetoengagein activities that create serious obstacles toaccessinghealthcareforsickorinjuredAfghans.

UnderInternationalHumanitarianLaw,medicalfacilitiesretainaprotectedstatus,aslongastheyareexclusivelydevoted tocareof thewoundedandsick. In2013therewasasharpincreaseinmilitary intrusions into health facilities in thecountry,with80%ofthoseincidentsattributedtopro-government forcesusinghealthcentresasbases formilitaryoperations.83Thesestatisticsare already worrying, but it is likely that manyincidents go unreported and that there aremultiplearmedgroupsinvolved.Suchintrusionsdamage the perception of health facilitiesas neutral, impartial spaces for healthcareprovision. They also expose health facilitiesto risk of direct attack from armed oppositiongroups, endangering the lives of patients andmedicalstaff.

“We didn’t have any governmentclinic near us until recently. Nowthere are always crowds of sickpeople there but no good qualitydoctorstotreatthemproperly.Also,inthepublicclinicthereisalotofqueuejumpingandcorruption.Youhavetopaythedoctorsabribetobeseen. They don’t really care aboutthe patients. They are just waitingintheirofficeforthedaytoendsotheycangohome.”Female,33years,Marjahdistrict,Helmandprovince

Informal charges for patients are particularlyworrying considering that cost was the secondmost important consideration, after proximity,forthosewhochoseapublichealthfacilityovera private one. More than one in six people inKunduz,andoneineightpeopleinHelmand,whochose to seek healthcare in a public structuredidsobecauseitwasconsideredthecheapest.However, the drugs were not always availableorfreeatthosepublicclinics,therebydrivinguptheirmedicalbills.

“There is a problem with the gov-ernment clinics in our area. Theyaresupposedtobefree,butthat’snotthereality.Even ifyoucanseethedoctorforfree,whenyouneedmedicines or tests, the doctorspush you towards their own pri-vateclinics.Theytellyoutheydon’thavethedrugsortheequipmentinthegovernmentclinicbutthattheyhaveeverythingintheirownprivatepractice.Oncetheygetyoutotheirprivate clinic, then you pay, pay,pay.Thishappensagainandagaintothepoorpeoplebecausenooneismonitoringtheseclinics.”Male,40,mullah,fromGharmsherdistrict,Helmandprovince ©

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“Alotofinjuredpeoplediebecauseofthedelaysintryingtoreachthehospital. The police will stop carstransportingtheinjured.Iftheyseeyou have an injured woman theydon’t stop you for too long. But ifthereare injuredyoungmen, thentheywillstopthecarandquestionthem to find out how they got theinjury. And these injured men candieatthecheckpoints,beforeevergetting to the hospital. It doesn’tmatter if the injured is a civilian,if he is an injured man, he can bestoppedanddelayed.”Male,25years,fromBaghlanprovince

Locatingmilitaryoutpostsorcheckpointsinthevicinityofaclinicmakeitmoredifficultforhealthprofessionalstoprovidehealthservicestothoseaffectedby,orinvolvedin,conflict.InKunduz,theAfghanNationalDirectorateofSecurityopenedan office in 2013 across the road from MSF’strauma centre. Community representativeshaveexplainedthatthepresenceofthismilitaryoffice so close to the hospital prevents peoplewounded in combat operations from seekinghealth services there, for fear of suspicion ofinvolvement intheconflict,orofarrest.Peoplespoke of similar fears in other areas of thecountry:

“Bothsideswillusuallyletyoupasswhenyou’reontheroadandtheyseeyouhaveaninjuredperson,aslongastheinjuredpersonisnotafighteror a government worker. If theinjuredpeopleareonthesideofthegovernment,iftheyaregovernmentworkers, then they will die. Theinsurgentswon’tallowthemtopassto thehospitalor to live.But ifyouare a wounded civilian who is notconnected to thegovernment, thentheinsurgentswillletyoupass.”Male,18years,fromLaghmanprovince,livinginDistrict12,Kabul

Under International Humanitarian Law, everyparty to the conflict must do its best to providespecial protection and care to sick and injuredcivilians and combatants, of which the right tomedical assistance is a fundamental provision.Healthprofessionalsalsohaveobligationstopro-videhealthservicesinanimpartialwaytopeopleaffectedby,orinvolvedinconflict,withoutdistinc-tionbasedonrace,ethnicityorpoliticalaffiliation.

While people spoke of many instances wherethey were given safe passage by the differentsides of the conflict, there are still too manyincidencesofthewarringpartiesfailingtofulfiltheir obligation to ensure access to medicalassistance.

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“If you manage to make it to thegovernment hospital, there ismoretroublewaitingforyou.Ifyoubringawoundedmantothepublichospital,thegovernmentwillsendan investigation team. They willaccusetheinjuredmanofbeingonthesideof the insurgentsandwillinterrogate him. They try to findout which party the man belongsto,whohemightbesupporting.Soinjuredmendon’twanttogotothehospital,becausetheyareworriedabouttheinvestigationteams.”Male,18years,shopassistant,fromLaghmanprovincelivinginDistrict12,Kabul

For sick or wounded Afghans, going to agovernment-run clinic or receiving assistancefrom groups affiliated with the counterinsurgency strategy can also bring the risk ofretaliation from the armed opposition groups(AOGs). When health and other public servicesarelinkedtopoliticalagendasandstrategiesofthebelligerentparties,doctorsandpatientsareexposedtoincreasedrisks.

“Ican’tgotothegovernmentdoctorinmyareabecauseoftheinsurgentsandotherproblems.Theydon’tlikeustogotoclinicssupportedbythegovernment.IfIgothere,maybetheinsurgents will arrest me and askwhyIwent,whatIwasdoingthere.Anyway, even if we were allowedto go, the people working in thoseclinicsarenotproperdoctors.”Male,22years,farmer,Nawzaddistrict,Helmandprovince

“We can’t go to the governmentclinics.Theinsurgentsdon’twantusto.Theydon’twantthisgovernment.They want their own government.Theytellusthatweshouldnottakefromthisgovernmentorgivetothisgovernment. So they don’t want ustousethegovernmentclinicsortheythinkthatwesupportthegovernment.Butsometimeswehaveto.Whenwedo, theyaskuswhywewent there.We have to explain that we didn’thave money to go somewhere else.Sometimes that’s enough reasonfor them, but if they don’t like youalready,youwillbeintrouble.”Female,43years,andbrother-in-law,48years,Sabaridistrict,Khostprovince

Even when the armed opposition may not havespecificproblemswithpeopleseekingtreatmentinapublicclinic,patientsmaystillavoiditbasedon fear and rumours about possible conse-quences. Violence – whether actual, threatenedorsimplyrumoured–createssignificantbarriersto accessing healthcare. Several patients spokeofavoidingthegovernmentclinicsintheirdistrictand embarking on long trips to other districts,andevenotherprovinces,tofindahospitalwherenooneknewthem.

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InadditiontothevariousAOGs,risingcriminalityincreases the volatility and insecurity of theenvironment for health workers and patientsalike. Violence against aid workers is growing,with the 2013 Aid Worker Security Reportreporting that Afghanistan was the mostdangerous country for aid workers.87 FromJanuary to June 2013, 125 incidents of violencewere recorded – an increase of 78% on thepreviousyear.AsofearlyDecember,theUNhadrecorded 237 incidents against humanitarianpersonnel,facilitiesandassets.Theseaccountedfor36deaths,24detentions,46injuriesandtheabduction of 72 personnel.88 Violations againsthealthworkersandfacilitiesarealsoreportedtobeontherise.89

Attacks on ambulances and health facilitiesdeprivethepopulationofmuch-neededmedicalservices. Following the explosion of a smalldevice in April 2012 inside its Khost maternityhospital, in which seven people were injured,MSFwasforcedtosuspenditsmaternalhealth

“Thereisnogovernmenthospitalinourarea.Iftherewereone,theothersidewouldnotwantustouseitbe-causeitbelongstothegovernment.I had to come here to this hospitallikeathief,likeacriminal,insecret,sopeoplefromthevillagewouldn’tknow. My son would have died if Ihadn’tbroughthimhere,butwhenIgetbackmaybeIwillbequestionedandharassedbecause Icamehereto this town. Though now everyoneback in the village is probably toobusy with all the fighting to havetimetowonderwhereIam.”Male,55years,farmer,MusaQaladistrict,Helmandprovince

services in the province, depriving women andchildren of urgently needed healthcare for theproceeding nine months. MSF reopened thehospital in December 2012 following a show ofstrong support and reassurances by the localcommunityandallrelevantparties.

Violence in Afghanistan injures patients andmedicalworkers,aswellasdestroyingmedicalstructures. Moreover, healthcare professionalsflee their posts, vaccination campaigns endabruptly, and clinics close, sometimes leavingentirecommunitieswithoutaccesstoadequateservices. International organisations providinghealthcare have also been forced to reviewtheiractivities,tightensecurityregulationsandreducepersonnel.Thiscompromisesthequalityof theaidprovidedandweakenstheirability toassessneedsandmonitoreffectiveness.

Today MSF is able to provide medical care tothousandsofpatientsthroughfourhospitals in

fourverydifferentprovinces,butstill thereareunknown needs outside the provincial capitalsthat the organisation is currently unable toassessoraddressduetosecurityconcerns.

“Two years ago we had an ambu-lance in our area, but then armedmen stole it. Now there’s nothingto transport the patients. Now youhavetopayfortaxis.Evenifthegov-ernment gave another ambulancetoourarea,theywouldn’tfindany-onetodriveit.Anydriverknowshewould risk being attacked becausehe’sworkingforthegovernment.”Male,25years,shopowner,fromMusaKheldistrict,Khostprovince

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ExTrA BArrIErS FOr wOMEN “Forpeoplelikeuswholivefaraway[fromthecentreofthedistrict],therearelotsofproblems.BecauseoftheviolenceandfightingyesterdayIhadto wait until morning to travel herewith my pregnant wife. Because ofthedelayherconditiondeteriorated.Shecollapsed three times,andnowsheisseriouslysick.”Male,37years,fromNahri-I-Sarajdistrict,Helmandprovince

In Afghanistan, women and children have adistinctlyhigherburdenofillnessanddeath,withthehighermortalityrateforwomenmainlydueto causes related to pregnancy and childbirth.While the maternal mortality ratio reportedlydeclined from 1,000 per 100,000 live births in2000to460per100,000livebirthsin2010,90thecountryisstilloneofthemostdangerousplacesin the world to give birth. During childbearingyears,onein42Afghanwomenislikelytodieofcausesrelatedtopregnancyandchildbirth.91

Whenwomenandgirlsneedtoaccesshealthcare,they must overcome specific obstacles, inparticular the dire shortage of qualified femalemedical staff in the country, especially in ruralareas.92 The limited acceptance of men ashealthcare providers for women means that thelack of female midwives, nurses and doctorsposesaclearobstacleformanywomen.

Maternal healthcare services are not welldistributedacrossthecountryandthemajorityofwomendonothaveadequateaccesstoessentialobstetric care. In general, qualified specialistsprefertoliveandworkinbigcities,whichleaveslarge gaps in healthcare provision in the ruralareas. The conflict further aggravates this, withthelimitedpoolof femaledoctorsandmidwiveseven more reluctant to work in the insecureareas. In provinces with USAID-funded projects,forexample,60%to70%ofruralhealthfacilitiesreportedalackoffemalehealthprofessionals.93

“Two of my sons died when theywereverysmall–onewhenhewasfivemonthsoldandtheotherwhenhewasonlytendays.Theybothhadfeveranddiarrhoea.Wedidn’tknowwhat was wrong with them – wehad no knowledge. When we tookthefive-month-oldboytothepublichospital in Kabul, the doctor theresaid it was too late. He died in thehospital.”Female,35years,fromKapisaprovince

Women in most areas of Afghanistan requireconsent from their husbands in order to visit ahealth facility. Once consent is obtained, theyareusuallyobligedtobeaccompaniedbyamalerelative. If there is no male available, this candelayorpreventthevisittoahealthcareprovider.Inthecaseofchildbirth,itcanmeanthatawomanwilldeliverathomeinsteadofinahealthfacilitywithaskilledbirthassistant,increasingtheriskofmorbidityormortalityfromcomplications.

“We live in a village far away fromhere.It’scheapertolivethefurtherfromthecentreyouare.Mymotherhasdiabetesandwhenshegetssickweneedtobringherallthewayintothecentreforcare.Manytimeswecan’tgobecausewecan’tfindamanwhohasenoughtimetoaccompanyus.Evenwhenshewasinjuredthistime,itwasreallydifficultforustogethere,becausewehadnomantocomewithus.”Female,43years,Kunduzdistrict,Kunduzprovince

MSF’s specialised maternity hospital inKhosttriestoovercomesomeofthespecificbarrierswomenface.Inordertohelpreducethehighmaternalmortalityrate inthearea,thehospitalprovidesasafeenvironment forwomentodelivertheirbabiesfreeofcharge,and opens up access to women who wouldotherwise be excluded from healthcare. In2013,staffperformedcloseto12,000deliveriesin2013.

In Khost, MSF tries to have an all-femalemedical teamprovidingcare to thepatients.However, the dearth of qualified femalemedicalworkerslivinginorwillingtorelocateto Khost remains a major challenge, even ifthepresenceofMSFinternationalstaffhelpsfill the gap. However, it is clear that manymore Afghan female medical staff will needto be trained in order to expand access toappropriatemedicalcareforwomen.

Giventhatthosefurthestawayfromthepro-vincial centre often face greater barriers toaccess healthcare, the focus for the Khosthospital in 2014 is on improving access forpregnantwomenfacingcomplications inpe-ripheraldistricts.MSFwill train localhealthworkers already working in those areas topromptly identify danger signs and facilitatethe safe transportation of these patients toMSF’s hospital. This should improve accesstothematernityhospital,buttherewilllikelystillbemanywomeninthemostremoteareaswhofacebarriersrelatingtodistance,costorsecuritythatwillcontinuetoblockthemfromreachingthehospital.

Evenifpublicclinicsdohaveafemalemidwife,nurseoradoctor,theclinics’openinghoursdonot fit with the medical reality of labour. Manyclinicsinthemoreremoteareasareonlyopeninthemorning,accordingtopatients.Consequently,womenreportedthatwhentheyortheirrelativesgointolabourorexperiencebleedinginthelateafternoonornight,theyareoftenunabletofindfreecarenearbyandareforcedeithertotravela long distance, at greater risk and cost, or todeliverathome.

“I’m here today with my pregnantdaughter-in-law. She started tohave complications yesterday butwedidn’thavethemoneyfortrans-port,soittooktoomuchtimebeforewecouldcome.Itravelledindangerto get here as fast as I could. Twomonths ago I came here with myniece.Therewastoomuchfightingtotraveltothehospital,soshedeliv-eredathome,butthebabydied.Be-forewecouldgetherhereforhelpwe had to wait nine hours for theviolence tostop.She isalive today.Butthatsamedayherbabydied,ourotherrelativewaskilledduringtheviolence.”Male,accompanying26-year-oldpregnantdaughter-in-law,fromGurbuzdistrict,Khostprovince

Only 20% of women in Afghanistan aged 15-24are literate,andthatnumber is three timeslowerinruralareas.94Lowliteracyrates,alackofknowledgeofhealthproblemsandpractices,andrestrictionsontheirmovementandaccessto money also limit women’s ability to accessproperortimelyhealthservicesforthemselvesandtheirchildren.

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Although the number of health facilities in Af-ghanistan has increased over the past decade,peopleinthefourlocationsrevealthattherearestill too few properly functioning or affordablehealthcentresclosetothemthattheytrust.Seri-ousshortcomingsinthereferralsystembetweenrural clinics and district or provincial hospitalsmean many Afghans do not have adequate ac-cesstosecondary-levelcare,includinglifesavingemergencysurgery.Pregnantwomenwithcom-plicationscontinuetodie,whilethewoundedrisktheirconditiondeterioratingwhenforcedtotravellongdistancestoseekmedicalcare.

People report that they must regularly pay fordrugs and often pay for informal doctors’ feesin public health facilities. Given the extremepoverty of many of those interviewed, it is vitalthat the national policy of free care is properlyimplemented.Medicinesandconsultationsmustbe free toensure thatmedicalexpensesdonotdeterpatientsfromseekingessentialhealthcare.Evenwhencare is free–as inallMSFprojectsin Afghanistan – non-medical costs such astransport and accommodation still pose majorhurdlesforpatientsandtheirfamilies.

Quality,ortheperceptionofquality,wasthemainreasonwhypeoplewenttoprivatehealthfacilities–whichoftentheycouldnotafford–orwhytheyundertook long journeys at great risk to reachclinics that they hoped would offer better carethantheirclosestpublicone.Afocusonimprovingboththecoverageandqualityofhealthfacilitiesis necessary, particularly in the most insecureareas, where basic and lifesaving medical careis often non-existent, prohibitively expensive orinaccessible.

There must be an improved response to reachcivilianstrappedinconflictandthoseinthemoreremoteregions,otherwisetheywillcontinuetofailtoreceivetheassistancetheyneed.Consideringthe volatile security situation outside provincialcapitals, existing rural health facilities need toremain open and properly functional. Bettermonitoring and evaluation of public facilities onthegroundtoimproveserviceswouldhelpinthisregard.

MSF’s research reveals the complex and grimrealityfacingpatientswho,inadditiontodealingwith the ongoing conflict, must also overcomefinancial and geographical barriers to accessthe medical care they need. It highlights thedestructive impact of the conflict, as the warinjures and kills civilians, interrupts basicservices, and impedes access to those servicesthat continue to function. Currently, healthcareprovision is insufficiently geared to meet risingmedical and emergency needs in Afghanistan,particularlythosestemmingfromtheconflict.

Theresearchrevealstheseriousandoftendeadlyrisksthatpeopleareforcedtotaketoseekbothroutineandemergencycare.Theyrisklandmines,checkpoints, harassment and active fighting ontheirjourneystodeliverababy,findtreatmentforamalnourishedchild,orsaveawoundedrelative.

Insecurity meant that MSF could only speak topatientsalready inside the fourhospitalswhereitsteamswork.Asaconsequence,theresearchlikelyunder-representstheextentofthebarriersfacedby thepoorestpeople living furthestawayfromtheprovincialcapitals,particularlythoseinthe most insecure areas. Beyond MSF’s reach,largenumbersofpeoplecontinuetosufferillnessorinjurywithoutrecoursetomedicalcare.

Since 2002, some important progress has beenmade inhealthcareprovision,and thisneeds tobe built on. Official accounts of Afghanistan’shealth system, however, habitually emphasiseachievements while neglecting unmet medicalhumanitarianneeds.Itisremarkablehowfartheprevailingnarrativesofprogressdiffer from theaccounts of ordinary Afghans. This report high-lightstheirexperiencesofobtainingmedicalaid,in order to galvanise an improved response totheirsituation.

Patientstoriesexposeawidegapbetweenwhatexists on paper in terms of healthcare facilitiesandservicesintheirareas,andwhatisavailableinreality.

CONCLUSION donorstrategies,itisimperativethatassistanceto civilians, in the form of humanitarian ordevelopment aid, is focused on addressing theactual needs, and is not contingent on trooppresenceortheoutcomeofpoliticalnegotiations.

International donors and aid providers musturgently address serious shortcomings inhealthcare provision. Healthcare policies havefrequently been overly focused on developing ahealthsystemfit forapost-conflictAfghanistanoftomorrow,ratherthanonethatalsoadequatelymeets the pressing needs of people today. Abetter balance is required between supportingthenecessarydevelopmentofthehealthsystemto meet basic and emergency needs, andensuringtheincreasedprovisionofindependenthumanitarianassistance.

Aid providers and belligerents alike mustsafeguard the neutrality and impartiality of aid.Parties to the conflict need to do far more toensure that independent, neutral and impartialhealthcare can be provided to all wounded andsick,includingtothosewhowereactivelyinvolvedin hostilities. In accordance with InternationalHumanitarian Law, medical personnel andfacilitiesmustberespectedatall times.Healthfacilitiesmustnotbeusedtoadvancepoliticalandmilitaryobjectivesorrequisitioned forpurposesotherthanprovidingcaretothesickandwounded.

With donor and media interest in the countrypredicted to wane following troop withdrawalat theendof2014,a renewed focuson the realexperiencesoftheAfghanpopulationisessential.AnydesiretopackageAfghanistanintoasimplifiedpoliticalormilitarysuccessstoryrisksmaskingtherealityoftheongoingconflictandthesufferingof hundreds of thousands of people who do nothaveaccesstoadequatemedicalassistance.

Astroopspacktheirbags,MSFseesawarthatstill rages in many parts of the country and afailure to meet people’s increasing medical andhumanitarianneeds.Itiscriticaltoprioritisethedeliveryoftangibleresultstoalleviatesuffering.While the international community may seekrefugeinrhetoric,theAfghanpeoplehavetodealwiththeharshreality.

The destruction and disruption of servicesdisproportionatelyaffectsthoselivinginmilitarilycontestedareas.However,insecurityandlimitedaccess to thosecommunitiesbyauthoritiesandhumanitarianagencies,includingMSF,preventsasustainedoradequateresponse.Thismeansthemostvulnerablearelefttofendforthemselves.

In an increasingly insecure environment, aidproviders must acknowledge the harsh realitythat humanitarian assistance is not reachingenoughofthepeoplewhoneedit.Humanitarianagencies,includingMSF,willneedtoaddresstheprevalent ‘bunker’ mentality that results in toomanyorganisationsconcentrated inmain townsand unable to access the most insecure areas.In such a volatile, politicised context, ensuringthatemergencycareisbroughtclosertopeoplewillbechallenging,butitisessential.Aspartofthis, health and humanitarian agencies have toprioritisenegotiatingaccesswithallsidesinthearmedconflict.

Where healthcare cannot feasibly be movedcloser,medicalaidprovidersneedtoaddresstheobstacles for transferringsickor injuredpeopletocarebyestablishingbetterfunctioningreferralmechanisms.Intheareaswhereitisabletowork,MSF is trying to address access issues throughvarious strategies. By increasing the numberof mobile clinics in the outskirts of Kabul, it isextendingitsreachintocommunitiesandmovingbeyonditshospitalwalls.ByimprovingthereferralofpatientsinHelmand,KunduzandKhost,MSFteams try to ensure that people’s journeys areless costly and less risky. MSF will continue tomakeeffortstoincreaseitsacceptanceamongallarmedgroupsandtoensuresafeaccessinordertoreachmoreofthemostvulnerablepeople.

The need to increase access to insecure areasunderlines the importance of both pragmaticand principled approaches. The provision ofboth relevant, effective basic services and ofhumanitarianassistancemustbeexpanded inatrulyneutral,impartialandindependentmanner.Aid provision must be more clearly untangledfrommilitaryandpoliticalagendas.

Decisionsonwhereandhowtoprovideassistancehave too often been based on desires forstabilisation, force protection, ‘winning heartsand minds’, or garnering political supportamongstthepublicbackhome.Inthepost-2014

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ANSF AfghanNationalSecurityForcesAOG ArmedOppositionGroupBPHS BasicPackageofHealthServicesBSA BilateralSecurityAgreementCERP Commander’sEmergencyResponseProgramCOIN Counter-InsurgencyEPHS EssentialPackageofHospitalServicesER EmergencyRoomGoA GovernmentofAfghanistanICRC InternationalCommitteeoftheRedCrossIQR InterquartileRangeISAF InternationalSecurityAssistanceForceMoPH MinistryofPublicHealthMSF MédecinsSansFrontièresNATO NorthAtlanticTreatyOrganizationNGO Non-GovernmentOrganisationOCHA OfficefortheCoordinationofHumanitarianAffairsPRT ProvincialReconstructionTeamUN UnitedNationsUSAID UnitedStatesAgencyforInternationalDevelopmentWHO WorldHealthOrganization

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12 International Monetary Fund, May 2008, “Islamic Republic of Afghanistan: Poverty Reduction Strategy Paper”, IMF Country Report No. 08/153, Available at: http://www.imf.org/external/pubs/ft/scr/2008/cr08153.pdf [Accessed on 14/12/2014].

13 UN Office for the Coordination of Humanitarian Affairs (OCHA), 22 November 2013, “2014 Afghanistan Humanitarian Needs Overview”, Available at: http://reliefweb.int/report/afghanistan/afghanistan-humanitarian-needs-overview-2014 [Accessed on 14/12/2014].

14 Integrated Regional Information Networks (IRIN) News, 2 January 2013, “Bleak 2013 humanitarian outlook for Afghanistan”, Available at: http://www.irinnews.org/printreport.aspx?reportid=97162 [Accessed on 14/12/2014].

15 Owen, G., 9 January 2014, “A Mutual Interdependency? The BSA and why the US still wants it”, Afghanistan Analysts Network, Available at: http://www.afghanistan-analysts.org/a-mutual-interdependency-the-bsa-and-why-the-us-still-wants-it [Accessed on 14/12/2014].

16 DeYoung, K, and Londoño, E., 25 January 2014, “Congress cuts U.S. military and development aid for Afghanistan”, The Washington Post Newspaper Online, Available at: http://www.washingtonpost.com/world/national-security/congress-cuts-us-military-and-development-aid-for-afghanistan/2014/01/24/3d4cb818-8531-11e3-bbe5-6a2a3141e3a9_story.html [Accessed on 14/02/2014]

17 Ryan, M., 21 January 2014, “U.S. eyes options for Afghanistan after Congress cuts aid”, Reuters News, Available at: http://www.reuters.com/article/2014/01/22/us-usa-afghanistan-aid-idUSBREA0L02320140122 [Accessed on 14/02/2014]

18 UN Assistance Mission in Afghanistan (UNAMA), 8 February 2013, “Afghanistan Annual Report 2013, Protection of Civilians in Armed Conflict’, UNAMA website, Available at: http://unama.unmissions.org/Portals/UNAMA/human%20rights/Feb_8_2014_PoC-report_2013-Full-report-ENG.pdf [Accessed on 14/02/2014]

19 UN Assistance Mission in Afghanistan (UNAMA), 8 February 2013, “Afghanistan Annual Report 2013, Protection of Civilians in Armed Conflict’, UNAMA website, Available at: http://unama.unmissions.org/Portals/UNAMA/human%20rights/Feb_8_2014_PoC-report_2013-Full-report-ENG.pdf [Accessed on 14/02/2014]

20 BBC News Online, 16 December 2013, “Afghanistan mission accomplished, says David Cameron”, News Report, Available at: http://www.bbc.co.uk/news/uk-politics-25398608 [Accessed on 14/02/2014]

21 UN High Commission for Refugees (UNHCR), 11 February 2014, “UNHCR welcomes Afghanistan’s new IDP policy”, UNHCR Briefing Note, Available at: http://www.unhcr.org/52fa062a9.html [Accessed on 14/02/2014]

22 UN High Commission for Refugees (UNHCR), “2014 UNHCR country operations profile – Afghanistan”, Available at: http://www.unhcr.org/pages/49e486eb6.html [Accessed on 14/02/2014]

23 UN Office for the Coordination of Humanitarian Affairs (OCHA), 22 November 2013, “2014 Afghanistan Humanitarian Needs Overview”, Available at http://reliefweb.int/report/afghanistan/afghanistan-humanitarian-needs-overview-2014 [Accessed on 14/12/2014].

1 Transparency International, December 2013, “Corruption Perceptions Index: Corruption around the world in 2013”, Press Release, Available at: http://www.transparency.org/news/pressrelease/corruption_perceptions_index_corruption_around_the_world_in_2013 [Accessed on 14/02/2014]

2 Poole, L., January 2011, “Afghanistan: Tracking major resource flows 2020 – 2010”, Briefing Paper, Global Humanitarian Assistance, Available at: http://www.globalhumanitarianassistance.org/wp-content/uploads/2011/02/gha-Afghanistan-2011-major-resource-flows.pdf [Accessed on 14/02/2014]

3 UN Development Programme (UNDP), “Human Development Report 2013. The Rise of the South:

Human Progress in a Diverse World”, New York, Available at http://hdr.undp.org/en/content/human-development-report-2013 [Accessed on 14/02/2014]

4 European Community Humanitarian Office (ECHO), July 2013, “Global Vulnerability and Crisis Assessment Final Index Rank 2013-2014”, Brussels, Available at: http://ec.europa.eu/echo/files/policies/strategy/gvca_2013_2014_en.pdf [Accessed on 14/02/2014]

5 UN Office for the Coordination of Humanitarian Affairs (OCHA), 22 November 2013, “2014 Afghanistan Humanitarian Needs Overview”, Available at http://reliefweb.int/report/afghanistan/afghanistan-humanitarian-needs-overview-2014 [Accessed on 14/02/2014]

6 U.S. Department of Defence, November 2013, “Report on Progress Toward Security and Stability in Afghanistan”, Available online at: http://www.defense.gov/pubs/October_1230_Report_Master_Nov7.pdf

7 Ruttig, T., 30 December 2013, “Some Things Got Better – How Much Got Good? A review of 12 years of international intervention in Afghanistan”, Afghanistan Analysts Network (AAN), Available at: http://www.afghanistan-analysts.org/some-things-got-better-how-much-got-good-a-short-review-of-12-years-of-international-intervention-in-afghanistan [Accessed on 14/12/2014].

8 Ruttig, T., 30 December 2013, “Some Things Got Better – How Much Got Good? A review of 12 years of international intervention in Afghanistan”, Afghanistan Analysts Network (AAN), Available at: http://www.afghanistan-analysts.org/some-things-got-better-how-much-got-good-a-short-review-of-12-years-of-international-intervention-in-afghanistan [Accessed on 14/12/2014].

9 World Bank Press Release, 7 August 2013, “$50 Million Grant to Boost Economic Growth and Fiscal Sustainability in Afghanistan”, Available at: http://www.worldbank.org/en/news/press-release/2013/08/07/50-million-grant-boost-economic-growth-fiscal-sustainability-afghanistan [Accessed on 14/12/2014].

10 BBC News, 8 July 2012, “Afghanistan aid: Donors pledge $16bn at Tokyo meeting”, Available at: http://www.bbc.co.uk/news/world-asia-18758148 [Accessed on 14/12/2014].

11 Central Intelligence Agency (CIA), “The World Factbook: South Asia: Afghanistan”, CIA Country Factsheet, Available at: https://www.cia.gov/library/publications/the-world-factbook/geos/af.html [Accessed on 14/12/2014].

ENDNOTES34 Ruttig, T., 25 January 2014, “Cards on the Table:

Transparency and post-2014 Afghan aid”, Afghanistan Analysts Network, Available at: http://www.afghanistan-analysts.org/cards-on-the-table-transparency-and-post-2014-afghan-aid [Accessed on 14/02/2014]

35 Humanitarian Outcomes, October 2013, “Aid Worker Security Report 2013 - The New Normal: Coping with the kidnapping threat”, Available at: https://aidworkersecurity.org/sites/default/files/AidWorkerSecurityReport_2013_web.pdf [Accessed on 14/02/2014]

36 Jackson, A., July 2013, “Taliban policy and perceptions towards aid agencies in Afghanistan”, Humanitarian Practice Network, Humanitarian Exchange Magazine, Issue 58, Available at: http://www.odihpn.org/humanitarian-exchange-magazine/issue-58/taliban-policy-and-perceptions-towards-aid-agencies-in-afghanistan [Accessed on 14/02/2014]

37 DiDomenico, V., Harmer, A., and Stoddard, A., April 2009, “Providing Aid in Insecure Environments: 2009, Update: Trends in Violence Against Aid Workers and the Operational Response”, Humanitarian Policy Group ,HPG Policy Brief 34: Available at: http://www.odi.org.uk/resources/docs/4243.pdf [Accessed on 14/02/2014]

38 Médecins Sans Frontières, 11 March 2010, �NATO statement endangers patients in Afghanistan�, News Release, Available at: http://www.doctorswithoutborders.org/press/release.cfm?id=4307&cat=press-release [Accessed on 14/02/2014]

39 Humanitarian Response Afghanistan, Common Humanitarian Action Plan (CHAP) 2014, Humanitarian Needs Overview, Available at: https://afg.humanitarianresponse.info/document/chap-2014-humanitarian-needs-overview [Accessed on 14/02/2014]

40 Integrated Regional Information Networks (IRIN) News, 12 February 2014, “Worsening Afghan humanitarian situation but lower appeal”, Available at: http://www.irinnews.org/report/99636/worsening-afghan-humanitarian-situation-but-lower-appeal [Accessed on 14/02/2014]

41 Agency Coordinating Body for Afghan Relief and Development (ACBAR), December 2013, “Protecting health-care and education facilities during the upcoming electoral process”, Statement, Available at: http://www.acbar.org/uploads/Advocacy/1060652097ACBAR%20health%20and%20election_%2016%2012%2013%20vf.pdf [Accessed on 14/02/2014]

42 Strong L, Waldman R, Wali A, December 2006, “Afghanistan’s Health System Since 2001: Condition Improved, Prognosis Cautiously Optimistic”, Afghanistan Research and Evaluation Unit (AREU), Briefing Paper Series,Available at: http://www.areu.org.af/Uploads/EditionPdfs/635E-Afghanistans%20Health%20System%20BP%202006%20web.pdf [Accessed on 14/02/2014].

43 Sandefur, J., 10 October 2013, “Here’s the Best Thing the U.S. Has Done: With the help of foreign aid, the public healthcare system has vastly improved the Afghan life expectancy”, The Atlantic online, Available at: http://www.theatlantic.com/international/archive/2013/10/heres-the-best-thing-the-us-has-done-in-afghanistan/280484/ [Accessed on 14/02/2014].

44 Palmer N, et al., 2006, “Contracting out health services in fragile states”, British Medical Journal (BMJ), 2006. Volume 332, pages 718-721.

24 UN Office for the Coordination of Humanitarian Affairs (OCHA), 22 November 2013, “2014 Afghanistan Humanitarian Needs Overview”, Available at http://reliefweb.int/report/afghanistan/afghanistan-humanitarian-needs-overview-2014 [Accessed on 14/02/2014]

25 European Union, October 2009, “National Risk and Vulnerability Assessment 2007/08: a profile of Afghanistan”, Kabul, Johoon Printing Press, Available at: http://ec.europa.eu/europeaid/where/asia/documents/afgh_nrva_2007-08_full_report_en.pdf, [Accessed on 14/12/2014].

26 The goal was to push the insurgents out, ensure they stayed out and then try to reinforce the government, strengthen security forces and improve the Afghan economy. The assumption was that outside military, political and development assistance would help eventually defeat the insurgency; support for the Afghan government would swell; and the international community could then dramatically reduce its military and financial presence in the country.

27 Sieff, K, 18 November 2013, “ In Kabul, clinic funded by U.S. military closing because of lack of government support”, The Washington Post, Available at: http://www.washingtonpost.com/world/in-afghanistan-clinic-funded-by-us-military-closes-because-of-lack-of-government-support/2013/11/17/64560b2a-4ad1-11e3-bf60-c1ca136ae14a_story.html, [Accessed on 14/12/2014].

28 Williamson, J. A., December 2011, “Using humanitarian aid to “win hearts and minds”: a costly failure?” International review of the Red Cross Vol. 93, no. 884, p. 1035-1061, Available at: http://www.cid.icrc.org/library/docs/DOC/irrc-884-williamson.pdf [Accessed on 14/12/2014].

29 Integrated Regional Information Networks (IRIN) News, 2 December 2009, “Afghanistan: USAID rejects NGO concerns over aid militarization”, Available at: http://www.irinnews.org/printreport.aspx?reportid=87288 [Accessed on 14/02/2014]

30 Special Inspector General for Afghanistan Reconstruction (SIGAR), October 2013, “Gardez Hospital: After almost 2 Years, Construction Not Yet Completed because of Poor Contractor Performance, and Overpayments to the Contractor Need to Be Addressed by USAID”, SIGAR 14-6 Inspection Report, Available at http://www.sigar.mil/pdf/inspections/SIGAR%202014-6-IP.pdf [Accessed on 14/02/2014]

31 Boak, J., 4 January 2011, “In Afghan hands, aid projects neglected”, The Washington Post, Available at: http://www.washingtonpost.com/wp-dyn/content/article/2011/01/03/AR2011010305647.html [Accessed on 14/02/2014]

32 Special Inspector General for Afghanistan Reconstruction (SIGAR), October 2013, “Walayatti Medical Clinic: Facility Was Not Constructed According to Design Specifications and Has Never Been Used”, SIGAR-14-10 Inspection Report, Available at: http://www.sigar.mil/pdf/inspections/SIGAR_14-10_IP.pdf [Accessed on 14/02/2014]

33 Special Inspector General for Afghan Reconstruction (SIGAR), April 2013, “ Health Services in Afghanistan: Two New USAID Funded Hospitals May Not Be Sustainable and Existing Hospitals Are Facing Shortages in Some Key Medical Positions”, SIGAR Audit 13-9, Available at: http://www.sigar.mil/pdf/audits/2013-04-29-audit-13-9.pdf [Accessed on 14/02/2014]

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of Public Health Vol 98; No. 10; pages.1849-1856. Available at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2636465/ [Accessed on 14/2/2014]

57 Markus, M., July 2011, “Too good to be true? An assessment of health system progress in Afghanistan 2002 – 2010”, University of Queensland/DANIDA, Available at: http://www.sph.uq.edu.au/docs/AfghanistanFinalAug11.pdf, [Accessed on xydate 2014].

58 World Health Organisation, “Afghanistan: health profile”, WHO website, Available at: http://www.who.int/gho/countries/afg.pdf?ua=1 [Accessed on 14/02/2014].

59 Viswanathan K. et al., August 2010, “Infants and under-five mortality in Afghanistan: current estimates and limitations”, Bulletin of World Health Organisation 2008; Volume 88: Number 8, pages 576-583. Available at: http://www.who.int/bulletin/volumes/88/8/09-068957/en/[Accessed on 14/02/2014].

60 World Bank website, “Afghanistan Overview”, Available at: http://www.worldbank.org/en/country/afghanistan/overview [Accessed on 14/02/2014].

61 Afghan Public Health Institute, Ministry of Public Health (APHI/MoPH) [Afghanistan], Central Statistics Organization (CSO) [Afghanistan], ICF Macro, Indian Institute of Health Management Research (IIHMR) [India], and World Health Organization Regional Office for the Eastern Mediterranean (WHO/EMRO) [Egypt], 2011, “Afghanistan Mortality Survey 2010”, Calverton, Maryland, USA: APHI/MoPH, CSO, ICF Macro, IIHMR and WHO/EMRO, Available at; http://www.measuredhs.com/pubs/pdf/FR248/FR248.pdf [Accessed on 14/02/2014].

62 Central Statistics Organisation (CSO) and UNICEF, 2012, “Afghanistan Multiple Indicator Cluster Survey 2010-2011”, Final Report. Kabul, Central Statistics Organisation (CSO) and UNICEF, Available at: http://www.childinfo.org/files/Afghanistan_2001-11_MICS_Final_Report.pdf [Accessed on 14/2/2014]

63 Markus, M., July 2011, “Too good to be true? An assessment of health system progress in Afghanistan 2002 – 2010”, University of Queensland/DANIDA, Available at: http://www.sph.uq.edu.au/docs/AfghanistanFinalAug11.pdf, [Accessed on 14/02/2014].

64 International Committee of the Red Cross (ICRC), June 2009, “Our World - Views from the Field: Summary Report: Afghanistan, Colombia, Democratic Republic of the Congo, Georgia, Haiti, Lebanon, Liberia, and the Philippines.” IPSOS & ICRC, Available at: http://www.icrc.org/eng/resources/documents/publication/p1008.htm [Accessed on 14/02/2014].

65 Shawe, K., “Afghanistan in 2013: A survey of the Afghan people”, The Asia Foundation, Available at: http://asiafoundation.org/resources/pdfs/2013AfghanSurvey.pdf [Accessed on 14/02/2014].

66 UN Office for the Coordination of Humanitarian Affairs (OCHA), 22 November 2013, “2014 Afghanistan Humanitarian Needs Overview”, Available at http://reliefweb.int/report/afghanistan/afghanistan-humanitarian-needs-overview-2014 [Accessed on 14/02/2014].

67 Ruttig, T., 30 December 2013, “Some Things Got Better – How Much Got Good? A review of 12 years of international intervention in Afghanistan”, Afghanistan Analysts Network (AAN), Available at: http://www.afghanistan-analysts.org/some-things-got-better-how-much-got-good-a-short-review-of-12-years-of-international-intervention-in-afghanistan [Accessed on 14/12/2014].

68 Ventevogel P, van de Put W, Faiz H, van Mierlo B, Siddiqi M, et al., 2012, “Improving Access to Mental Health Care and Psychosocial Support within a Fragile Context: A Case Study from Afghanistan”, PLoS Med 9(5): e1001225. doi:10.1371/journal.pmed.1001225, Available at: http://www.plosmedicine.org/article/info%3Adoi%2F10.1371%2Fjournal.pmed.1001225 [Accessed on 14/12/2014].

45 Pavignani E, Colombo S., 2002, “Afghanistan health sector profile. A contribution to the debate on health sector recovery”, Afghan Information Management Services, Kabul, Available at: http://www.aims.org.af/services/sectoral/health/health_sector_profile_aug_02.pdf [Accessed on 14/02/2014].

46 Palmer N, et al., 2006, “Contracting out health services in fragile states”, British Medical Journal (BMJ), 2006. Volume 332, pages 718-721.

47 The BPHS and EPHS are the core of Afghanistan’s current health system and provide different levels of health services. The BPHS provides primary health care services—such as immunizations and prenatal care—at small and rural health clinics and forms the core of health service delivery for all primary care facilities in Afghanistan. The EPHS guides the medical services each type of hospital should provide in terms of general services, staff, equipment, diagnostic services, and medications and promotes a health referral system that tries to integrate the BPHS with hospitals, from the district to the provincial to the regional level.

48 Shawe, K., “Afghanistan in 2013: A survey of the Afghan people”, The Asia Foundation, Available at: http://asiafoundation.org/resources/pdfs/2013AfghanSurvey.pdf [Accessed on 14/02/2014].

49 World Health Organisation (WHO), “Official development assistance (ODA) for health to Afghanistan”, WHO, Geneva, Available at: http://www.who.int/gho/governance_aid_effectiveness/countries/afg.pdf [Accessed on 14/02/2014].

50 World Health Organisation (WHO), UN Children�s Fund (UNICEF), 2012, �Afghanistan : Countdown to 2015 : maternal, newborn and child survival. Building a future for women and children : the 2012 report ”, WHO and UNICEF, Geneva, Available at: http://www.countdown2015mnch.org/documents/2012Report/2012/2012_Afghanistan.pdf [Accessed on 14/02/2014]..

51 Edward A, Kumar B, Kakar F, Salehi AS, Burnham G, et al., July 2011, “Configuring Balanced Scorecards for Measuring Health System Performance: Evidence from 5 Years’ Evaluation in Afghanistan”, PLoS Med Volume 8, Issue 7: e1001066. Available at: http://www.plosmedicine.org/article/info%3Adoi%2F10.1371%2Fjournal.pmed.1001066 [Accessed on 14/2/2014].

52 Peters D. et al, February 2007, “A balanced scorecard for health services in Afghanistan”, Bulletin of the World Health Organisation, Volume 85; 146-151.doi: 10.2471/BLT.06.033746 Available at: http://www.who.int/bulletin/volumes/85/2/06-033746.pdf [Accessed on 14/2/2014].

53 Hansen P., Peters D., Edward A., Gupta S., Arur A., Niayesh H., and Burnham G., 2008, “Determinants of primary care service quality in Afghanistan” International Journal for Quality in Health Care (2008) 20 (6): 375-383 first published online September 16, 2008 doi:10.1093/intqhc/mzn039 Available at: http://intqhc.oxfordjournals.org/content/20/6/375.full [Accessed on 14/2/2014].

54 Steinhardt L. et al., 2009, “The effect of wealth status on care seeking and health expenditures in Afghanistan”, Health Policy Plan, 2009; 24 (1): pages1-17. doi: 10.1093/heapol/czn043. Epub 2008 Dec 5 Available at: http://www.ncbi.nlm.nih.gov/pubmed/19060032 [Accessed on 14/2/2014].

55 Johns Hopkins University Third-Party Evaluation Team, 2008. “Final evaluation report on health financing pilots: the effects of user fees vs. free services on primary care.” Unpublished report, Johns Hopkins University. Kabul, Afghanistan

56 Mayhew M, Hansen PM, Peters DH, Edward A, Singh LP, et al., 2008, “Determinants of skilled birth attendant utilization in Afghanistan: a cross-sectional study”, American Journal

Needs Overview”, Available at http://reliefweb.int/report/afghanistan/afghanistan-humanitarian-needs-overview-2014 [Accessed on 14/02/2014]

83 UN Office for the Coordination of Humanitarian Affairs (OCHA), 1 October 2013, “Afghanistan: Protection of Civilians Snapshot (as of 1 October 2013)”, Infographic, Available at: http://reliefweb.int/report/afghanistan/afghanistan-protection-civilians-snapshot-1-october-2013 [Accessed on 14/02/2014]

84 Agency Coordinating Body for Afghan Relief and Development (ACBAR), 2013, “Afghanistan Case Study – Access to Health Care”, Unpublished Briefing Paper

85 Agency Coordinating Body for Afghan Relief and Development (ACBAR), December 2013, “Protecting health-care and education facilities during the upcoming electoral process”, Statement, Available at: http://www.acbar.org/uploads/Advocacy/1060652097ACBAR%20health%20and%20election_%2016%2012%2013%20vf.pdf [Accessed on 14/02/2014]

86 Agency Coordinating Body for Afghan Relief and Development (ACBAR), December 2013, “Protecting health-care and education facilities during the upcoming electoral process”, Statement, Available at: http://www.acbar.org/uploads/Advocacy/1060652097ACBAR%20health%20and%20election_%2016%2012%2013%20vf.pdf [Accessed on 14/02/2014]

87 Humanitarian Outcomes, October 2013, “Aid Worker Security Report 2013 - The New Normal: Coping with the kidnapping threat”, https://aidworkersecurity.org/sites/default/files/AidWorkerSecurityReport_2013_web.pdf [Accessed on 14/02/2014]

88 United Nations (UN), 2 December 2013, “After recent attacks on Afghan aid workers, UN official urges respect for humanitarian staff”, Press Release, UN News Centre, Available at: http://www.un.org/apps/news/story.asp?NewsID=46643&Cr=afghan&Cr1=#.UuTmznmCqgQ [Accessed on 14/02/2014]

89 UN Office for the Coordination of Humanitarian Affairs (OCHA), August 2013, “Humanitarian Bulletin: Afghanistan”, Issue 19, OCHA website, Available at: http://reliefweb.int/sites/reliefweb.int/files/resources/Afghanistan%20HB%20Issue19%2030August2013.pdf [Accessed on 14/02/2014]

90 World Health Organisation, “Afghanistan: health profile”, WHO website, Available at: http://www.who.int/gho/countries/afg.pdf?ua=1 [Accessed on 14/02/2014].

91 Calculated based on a maternal mortality ratio of 460 per 100,000 live births and a fertility rate of 5.1.

92 Mansoor, F., Hill, P. S., and Barss P., January 2012, “Midwifery training in post-conflict Afghanistan: tensions between educational standards and rural community needs”, Health Policy Plan, 27(1), pages 60-68. doi: 10.1093/heapol/czr005, Available at: http://www.ncbi.nlm.nih.gov/pubmed/21278372 [Accessed on 14/02/2014]

93 Markus, M., July 2011, “Too good to be true? An assessment of health system progress in Afghanistan 2002 – 2010”, University of Queensland/DANIDA, Available at: http://www.sph.uq.edu.au/docs/AfghanistanFinalAug11.pdf, [Accessed on 14/02/2014]

94 Oates, L., 21 June 2013, ‘The mother of all problems: female literacy in Afghanistan”, Guardian Newspaper Online, Available at: http://www.theguardian.com/global-development-professionals-network/2013/jun/21/funding-education-in-afghanistan [Accessed on 14/02/2014]

69 Silberner, J., 17 October 2011, “Uneven global progress on treatment of mental illness”, National Public Radio (NPR), Shots: Health News, Available at; http://www.npr.org/blogs/health/2011/10/14/141365426/uneven-global-progress-on-treatment-of-mental-illness [Accessed on 14/12/2014].

70 European Union, October 2009, “National Risk and Vulnerability Assessment 2007/08: a profile of Afghanistan”, Kabul, Johoon Printing Press, Available at: http://ec.europa.eu/europeaid/where/asia/documents/afgh_nrva_2007-08_full_report_en.pdf, [Accessed on 14/12/2014].

71 United States Agency for International Development (USAID), “Health”, Website Article, Available at: http://www.usaid.gov/afghanistan/health [Accessed on 14/2/2014]

72 Special Inspector General for Afghan Reconstruction (SIGAR), July 2013, “SIGAR responds to State Department, USAID and Department of Defense list of 10 best and 10 worst reconstruction projects in Afghanistan”, Letter, Available at: http://www.sigar.mil/pdf/spotlight/2013-07-03 Top 10 Response.pdf [Accessed on 14/2/2014]

73 World Bank, PovCalNet Available at: http://iresearch.worldbank.org/PovcalNet/index.htm?2

74 Central Statistics Organisation (CSO) and World Bank, May 2012, “Setting the official poverty line for Afghanistan” Washington D.C., Available at: http://cso.gov.af/Content/Media/Documents/CSO-WB_Tech-Report-Pov_v4(2)1162011121045651553325325.pdf [Accessed on 14/2/2014]

75 Central Statistics Organisation (CSO) and UNICEF, 2012, “Afghanistan Multiple Indicator Cluster Survey 2010-2011”, Final Report. Kabul, Central Statistics Organisation (CSO) and UNICEF, Available at: http://www.childinfo.org/files/Afghanistan_2001-11_MICS_Final_Report.pdf [Accessed on 14/2/2014]

76 In literature, it is estimated that a payment of the equivalent of two days expenditure can deter people from seeking care or delaying care for an out-patient consultation. “Catastrophic health expenditure” is said to occur when households’ health expenditure exceeds 40% of their remaining income after subsistence needs have been covered, creating a serious risk of impoverishment.

77 Markus, M., July 2011, “Too good to be true? An assessment of health system progress in Afghanistan 2002 – 2010”, University of Queensland/DANIDA, Available at: http://www.sph.uq.edu.au/docs/AfghanistanFinalAug11.pdf, [Accessed on 14/02/2014].

78 Edward A, Kumar B, Kakar F, Salehi AS, Burnham G, et al., July 2011, “Configuring Balanced Scorecards for Measuring Health System Performance: Evidence from 5 Years’ Evaluation in Afghanistan”, PLoS Med Volume 8, Issue 7: e1001066. Available at: http://www.plosmedicine.org/article/info%3Adoi%2F10.1371%2Fjournal.pmed.1001066 [Accessed on 14/2/2014].

79 Palmer N, et al., 2006, “Contracting out health services in fragile states”, British Medical Journal (BMJ), 2006. Volume 332, page 718-721.

80 Markus, M., July 2011, “Too good to be true? An assessment of health system progress in Afghanistan 2002 – 2010”, University of Queensland/DANIDA, Available at: http://www.sph.uq.edu.au/docs/AfghanistanFinalAug11.pdf, [Accessed on 14/02/2014].

81 Ridde V. and Bonhoure, P., December 2002, “Performance based partnership agreements in Afghanistan,“ Letter to the Editor, The Lancet, Vol 360, Issue 9349, Pages 1976-1977. doi:10.1016/S0140-6736(02)11873-3 Available at: http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(02)11873-3/fulltext [Accessed on 14/02/2014].

82 UN Office for the Coordination of Humanitarian Affairs (OCHA), 22 November 2013, “2014 Afghanistan Humanitarian

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