Challenges faced by healthcare workers in Afghanistan amidst the COVID-19 pandemic and political instability: A call for action

Afghanistan is a non-coastal country with 34 provinces and almost 30 million people, located halfway between the Middle East, Central Asia, and South Asia. Over the years, conflicts negatively impacted Afghanistan's public and private sector services, including healthcare services. Healthcare workers were not left out as they have been at the centre point of the crisis since the early days due to the insubstantial condition of the dooming country. Moreover, the number of healthcare workers is lower than the World Health Organisation (WHO) recommended physician to population ratio, which stood at 0.278 per 1000 people in 2016.¹ Hence, this added a considerable burden on healthcare workers.

During the COVID-19 pandemic, healthcare workers took resolute action to prevent the spread of the infection within the country. The healthcare system implemented mitigating strategies such as increasing testing kits and equipment, establishing treatment centres, quarantine facilities, and control measures in the community. Despite the challenges, healthcare workers showed resilience and fulfilled their duty to contain the pandemic. However, healthcare workers also sacrificed a lot in combating COVID-19 despite the lack of personal protective equipment and overcrowded beds.² A total of 96 healthcare workers died in the fight against COVID-19.³ The actual number might even be higher given that the country lacks a robust surveillance and reporting system and national death register. This is considered a significant loss for the country whose healthcare workers are inadequate compared to the country's population.

Amidst the pandemic, healthcare workers were the target of the horrific attacks, including the famous maternity hospital, which took the lives of many healthcare workers.⁴ In the recent past, a group of armed men abducted one of Afghanistan's most distinguished doctors on his way home from work in the northern city of Mazār-i-Sharīf, where they had just opened the country's first private psychiatric hospital. Since its inception in 2004, it has treated thousands of Afghans, including Taliban combatants.⁵ More recently, 20 people have been killed and at least 16 injured in a gun and bomb assault on a military hospital in the Afghan capital Kabul. The Sardar Daud Khan hospital has been targeted before. More than 30 people were killed and 50 others wounded in 2017 when shooters dressed as doctors stormed the building.⁶ Unfortunately, the country has not provided sufficient security for its healthcare workers. Therefore, healthcare workers in Afghanistan have not been able to work effectively as a result of mental health symptoms such as anxiety and depression arising from the ever-threatening environment.⁷

The country commenced the COVID-19 vaccination program with frontline healthcare workers and planned to extend it to the community during the last week of January 2021. The healthcare workers roll out the vaccination in hospitals for elderly and young people as per the international guidelines. However, given the vaccine shortage in the country, the fight against COVID-19 remained relatively uncertain. Misinformation on the vaccine, low confidence in the availability of the vaccine, and vaccine hesitancy among the population during the first, second, and third waves have escalated the number of the COVID-19 cases, therefore, adding more burden on the already exhausted healthcare workers.⁸ Some factors that may be responsible for vaccine hesitancy include complacency, convenience, and public confidence in the government. Even though the public showed interest in the effort made in the production of the COVID-19 vaccine as the infection continued to spread, not many countrymen/women believed the government could provide the vaccine in 2021.⁸ This is majorly due to budget constraints, prevalent corruption, and unstable security which could affect the provision and distribution of the COVID-19 vaccine to the populace.⁸ The Afghanistan government is currently coordinating with international NGOs and donors, describing the challenges that healthcare workers are facing and suggesting ways for the resumption of funding as it is the primary source for health care delivery in the country.

The United State of America's (USA) withdrawal has massively intensified the challenges for the healthcare workers. Currently, the situation in Afghanistan is getting out of control for the whole population, including healthcare workers. The massive economic crisis has forced many people into intense poverty.⁹ Healthcare workers are not being paid their salaries and allowances for months.¹⁰ This has caused mental health issues as the economic crisis continues surging. The country's fragile situation will further deteriorate with the imminent approach of the freezing winter season.

At this critical juncture, the country's largest health services provider, the "Sehetmandi program," is not functioning correctly, with only 17% of the project in operation. The project aimed to deliver healthcare services across the country,¹¹ and was running on international aid and funding. Since the USA's withdrawal, the World Bank, one of the project's main funders, has stopped funding the country's largest health project. This has created ripple effects for the healthcare system, as hospitals operate with minimum resources.¹² Moreover, COVID-19 hospitals are no longer functioning due to inadequate support. Healthcare workers are overwhelmed with the influx of patients and a staff shortage. This is because many healthcare workers left the country because of political instability.¹³ Recommendations to enhance healthcare providers' support have been listed in Box 1 .

Box 1. Recommendations to enhance support to healthcare workers in Afghanistan.

• •To improve healthcare delivery services across Afghanistan, the government should integrate informal care providers into their national health strategies and quality monitoring and improvement efforts. This is because of the shortage of healthcare workers. The government should acknowledge that these informal providers exist and undertake measures to assess and improve the care they provide, such as through formal, informal education, training, and incentives, to the fullest extent possible.
• •High priority should be focused on areas with extreme adversities like Afghanistan. The international humanitarian system, multilateral organizations, and NGOs should identify priority areas for assessing the quality of care in these settings, not only to patients but also to the healthcare workers responsible for providing care. They should develop strategies for its improvement. Emphasis should be placed on addressing burdensome conditions in such settings, especially to healthcare workers, such as treating conflict-related trauma and mental illness and protecting providers from conflict-related harm.
• •Multilateral organizations and the United Nations System should create multi-stakeholder collaborations for purposes of reviewing and vetting the available evidence; developing consensus on promising interventions for the improvement of the quality of life of healthcare workers in particular circumstances, such as conflict zones, humanitarian crises, and fragile states such as Afghanistan.
• •Salaries of the healthcare workers should be recompensated on time to prevent mental health and psychosocial challenges among them.
• •World Bank should restart its funding in Afghanistan and support the health services packages across the country, which will boost the locally-led effort necessary to rejuvenate the process again.
• •International communities must pressure the new government to ensure female healthcare workers are involved in the healthcare delivery without any fear and apprehension.
• •Ensuring healthcare workers' safety, health, and well-being should be a top global health priority in light of the trend of violence against healthcare workers, as reported in Afghanistan. The Taliban government must collaborate with Humanitarian agencies to offer security to the Afghan people and healthcare workers.
• •Inequitable distribution of COVID-19 vaccines, as well as the inherent problems of delivering health services in war-like contexts, compound the difficulties faced by healthcare professionals. Because healthcare workers are at the highest risk of contracting COVID-19, it is recommended that they receive at least one dose of the life-saving SARS-CoV-2 virus vaccine.
• •The pandemic has given healthcare staff a more significant task than they've ever had before while also making their work more difficult and riskier. Their health and well-being must be prioritized urgently in global initiatives and state policies.
• •There is a need to build an effective social health protection system that would provide universal access to health care workers' requirements that is inexpensive, available, of appropriate quality, and provides financial protection in times of illness, accident, and maternity period.

Alt-text: Box 1

To conclude, the ongoing calamities in Afghanistan have prolonged the suffering of healthcare workers. Economic crisis, political instability, and shortage of healthcare workers have all raged the condition of the healthcare workers. Therefore, it is high time international communities intervene swiftly to alleviate the situation of healthcare workers. Otherwise, the crisis would continue plaguing the healthcare workers, and the country's healthcare system would reach its threshold and certainly collapse.

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Credit authorship contribution statement

SS: Conceptualization, Formal analysis, writing – original draft, Data curation, Validation, Visualization, Investigation, Project administration, Resources, Supervision, Writing – review & editing. SMS & MYE: Formal analysis, Writing – original draft, Data curation, Validation, Visualization. AYA: Data curation, Formal analysis, Writing – review & editing, Supervision.

Declaration of competing interest

The authors declare that they have no competing interests.