Access to healthcare services for Afghan refugees and deepening medical crises due to war amidst COVID‐19 pandemic

In 2001, the new and under‐resourced Afghan government worked on rebuilding the shattered healthcare system. After a two‐decade war with the US‐supported Afghan government, the Islamic Emirate of Afghanistan (Taliban) took over most of Afghanistan by 18th August 2021. Amidst the conflict, the coronavirus‐2019 (COVID‐19) disease was declared a global emergency. Like most other low‐ and middle‐income countries, war‐stricken Afghanistan has also been hit hard, reporting a total of 152,497 cases of COVID‐19, and 7065 deaths as of 20 August 2021. ¹

During the pandemic, economic instability across the globe led to an influx of refugees from European Unions, Pakistan and Iran back to Afghanistan. Additionally, Internally Displaced People (IDP) from remote Afghanistan have fled to bigger cities like Kabul, ² cramping refugee camps and burdening the available sanitation facilities. The increasing incidence of COVID‐19‐like symptoms amongst the Afghans is a result of a lack of social distancing. Conflict and unemployment have led to malnutrition, while unsanitary conditions have emancipated GI‐related conditions in the local population. ³ With little attention to the social needs, the prospect of a crumbling healthcare system will be evident if the polio‐endemic re‐emerges in the country. ⁴

WHO recommends 22.8 skilled healthcare professionals per 10,000 individuals; Afghanistan only has 9.4 skilled healthcare professionals. ⁵ The shortage of healthcare workers is predicted to increase as financial insecurity and fear of political unrest drives many out of Afghanistan. ⁶ The attack on Dasht‐e‐Barchi in 2020, a government‐run maternity hospital in Kabul, took the lives of healthcare professionals and patients, jeopardizing women's access to basic health care. ⁵ Since then, non‐profit organizations like Médecins Sans Frontières (Doctors Without Borders) have withdrawn from serving the country, jeopardizing all contributions to health care made in the past 17 years. In the six months preceding the invasion of the Taliban, armed attacks on healthcare workers killed 12 and damaged 26 medical facilities. ³ Between August 1st and 6th, MSF has reported having treated over 150 patients with war‐inflected traumas. ⁷ Scattered hospitals and clinics make patient transfers from remote areas difficult, delaying treatment. Adding to this is the issue of inadequate diagnostic facilities which has affected coronavirus testing. ⁸ The B.1.617.2 (delta) variant, with higher morbidity and mortality has been detected in 60% of the cases in Afghanistan. ⁷

With a majority of Afghans earning only USD 1 per day, living below the poverty line has made treatment, COVID‐19 tests and vaccines unaffordable. Under the COVAX agreement, the Afghanistan Ministry of Public Health received initial doses of COVID‐19 vaccines. However, as war affects trade routes, the rate of COVID‐19 vaccination has seen a decline, with many awaiting their second dose. ⁷ Afghans seeking asylum under these conditions risk the spread of coronavirus infection in countries of immigration.

Although developed nations such as Germany have raised 17 million euros for healthcare and other projects in Afghanistan, ⁹ a strategic policy change is required to sustain Afghanistan. UNDP and Aid Community collaboration has allowed the home‐based provision of healthcare to IDP which has highly benefitted women and children. ² Ministry of Health Policy had previously introduced a pay‐for‐performance ‘Sehatmandi’ project, funded by the World Bank. This was able to sustain the burden of caesarean deliveries, surgeries, and outpatient visits for vaccinations. In current times of political instability, this model is necessary for a successful healthcare delivery system. ¹⁰

Vietnam has suffered a similar fate as Afghanistan, thus modified low‐cost models can be adopted by the Ministry of Health Policy to prevent the collapse of healthcare in Afghanistan. The coronavirus low‐model cost could be altered to increase refugee camps to observe social distancing, spread awareness about cloth masks, and while closing borders seems impossible, quarantining at borders is a possibility. ¹¹ As the country's resources and facilities are expected to be exhausted in conflict, health care should be built on the Basic Package of Health Purposes. Like the situation in 2001, this allowed policies to be translated into primary healthcare facilities which benefitted healthcare delivery in rural areas. Following the old Afghan model, international and private NGOs can introduce midwifery and nursing through community‐based training, recruiting women mainly. ⁶

UN estimated USD 1.1 billion to rebuild a sustainable healthcare infrastructure in Afghanistan. ⁹ If the medical crisis at hand does not receive immediate global attention, Afghanistan will foresee a humanitarian catastrophe, with Afghans suffering from recurring diseases like drug‐resistant tuberculosis, respiratory tract infections, anaemia and skin infections. ¹²

CONFLICT OF INTEREST

The authors declare no conflict of interests.

ETHICS STATEMENT

This manuscript is the authors' original work, which has not been previously published elsewhere. All authors have been actively involved in substantial work leading to the paper and take public responsibility for its content.

DATA AVAILABILITY STATEMENT

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