Afghanistan’s healthcare system is facing serious challenges in providing vital care due to a growing funding shortfall caused by cuts from aid organizations and donor governments in the wake of the Taliban’s return to power, Afghan doctors and international health officials warn.

On 31 August, the International Committee of the Red Cross announced it was terminating a project funding 25 government-run hospitals across Afghanistan for nearly two years, as part of the organization’s efforts to cut more than $475 million of costs globally.

The ICRC insists that support to the Afghan hospitals, which covered everything from the salaries of more than 10,000 health workers to medicines and ambulance and generator fuel, was only ever meant to be a temporary response to the Taliban’s 2021 return to power.

The so-called Hospital Resilience Programme was never envisioned as a “substitute or replacement for government functions” in the country, ICRC spokesperson Jason Straziuso told The New Humanitarian.

But the move, which affects the largest and most critical hospitals in the country, comes as the Taliban’s Islamic Emirate government – hit by sanctions, the freezing of billions of dollars in Afghan reserves, and an economic crisis – struggles to fill a gaping void: The former Western-backed Islamic Republic government was reliant on foreign aid for 75% of its operating budget.

Despite assurances from Kabul and the international community, several Afghan doctors told The New Humanitarian that the current state of the healthcare system is already proof that it remains reliant on international aid and the work of NGOs.

“Up until now, it has been the foreign assistance that has held the Afghan healthcare system up,” said Hamid Sharaf, a surgeon at Kabul’s state-owned Jamhuriat Hospital, which was part of the ICRC’s resilience programme. “Both during the Republic and [under the Taliban], it has been impossible for the healthcare system to stand on its own without foreign aid.”

“For a country already affected by decades of conflict, underfunding of the healthcare system is a critical humanitarian concern.”

The ICRC is far from the only international group still working to bolster the Afghan healthcare system, which is confronting one of the world’s worst humanitarian crises, with 28.3 million of its 43 million people requiring urgent humanitarian assistance, according to the UN.

USAID, for example, has spent $309.3 million on 13 Afghan health programmes over the last two years. The EU is also continuing its support, last week announcing a newly opened EU-funded health centre in the western province of Herat that can treat up to 15,000 people. Qatar has also pledged to provide life-saving medicine to 11 of the nation’s 34 provinces.

However, the World Health Organization says it’s not nearly enough for the 14 million Afghans in need of vital health services this year. It is warning that the health sector still requires a further $413 million in assistance, with the WHO itself calling for an additional $125 million for its Afghan operations, including for its efforts in 33 hospitals.

“For a country already affected by decades of conflict, underfunding of the healthcare system is a critical humanitarian concern,” Dr. Luo Dapeng, WHO’s Afghanistan representative, said weeks before the ICRC’s cuts took effect. “The consequences of this underfunding cannot be overstated.”

Sharaf said past experience shows it may be an uphill battle, especially for a government facing so many diplomatic and economic difficulties. In August, Britain came under criticism for its 76% cut in aid to the country. The United States also said Washington and its allies would cut $2 billion in aid to Afghanistan due in part to the Islamic Emirate’s growing social, economic, and educational restrictions on women.

In 2018, when the Republic was still in power, researchers pointed out that basic services, including health, were largely being delivered by NGOs. At the time, the British-funded research stated: “It is unclear whether, in the absence of international aid, the government would be able to provide these services.”

With the recent aid cutbacks, that premise is being put to the test. Only now, Afghanistan is being ruled by a government that has been largely ostracised by the outside world while dealing with an economic downturn and crippling financial and banking restrictions.

The New Humanitarian spoke to doctors across Afghanistan who painted a picture of a healthcare system that is already under considerable strain and failing to provide care to certain groups.

Sharifa Wardak, a doctor who has spent more than 20 years training midwives in Maidan Wardak, said 70% of clinics are currently open in the southeastern province but nearly all of them are either funded or run by foreign aid organizations.

The Swedish Committee of Afghanistan alone operated 77 facilities, including the largest hospital in the provincial capital, Maidan Shahr. But the SCA had to suspend some of its work in July after the Islamic Emirate ordered a halt to all Swedish activity in Afghanistan in response to a Koran-burning incident in the Scandinavian country.

As just one example of how the aid cutbacks are affecting women and children in under-developed areas like Maidan Wardak, Wardak explained how she and other health workers have had to stop providing iron folic acid and high-energy biscuits to pregnant women and malnourished children.

“A lot of these patients are anemic and can’t afford to buy fruit and vegetables,” said Wardak.

And it’s not just a few smaller community-based clinics in some of the more remote areas that are feeling the pinch.

Najibullah Nusra, chief physician at the the 100-bed Wazir Mohammad Akbar Khan Hospital in Kabul, said hospitals across the country had begun to rely on ICRC support over the past two years and now are at a loss to know how they will operate.

Despite cutbacks, the ICRC insists it isn't leaving Afghanistan and will continue with its core programmes, including the in-country creation of prosthetics for war victims.

“They handled payment for everything, from A to Z,” Nusra said. “If we needed a syringe or a pencil, they’d pay for it.”

Nusra said that when the ICRC programme first started, the hospital would receive up to seven million Afghanis, about $89,000, for its monthly expenses. In recent months, that number had fallen to around three million Afghanis, or just over $38,000, and now nothing.

Sharaf said that when the ICRC stopped funding pharmaceutical purchases for the 25 government-run hospitals, Jamhuriat’s patients felt an immediate effect.

“We were running out of medicine, and patients had to purchase their own prescriptions elsewhere,” he said. With up to 900,000 jobs having been lost over the last two years, Sharaf said even the cost of a few antibiotics can take a huge financial toll on families who turn to the nation’s 4,854 government-run hospitals and clinics for care.

“The entire country is dealing with these economic shocks, and now patients have to once again buy their own medicines. For a lot of families, that is a considerable expense,” Sharaf said, adding that filling prescriptions out in pharmacies that are not in hospitals leaves patients susceptible to purchasing expired or low-quality medicines.

Health workers fear the additional costs to patients won’t be limited to just medicines.

Momtaz Yusufzai, who has spent 23 years working in child health services, recalled how in the past when hospitals in Afghanistan have struggled financially, patients have even had to purchase gloves and masks for hospital staff to use during their treatments.

But the implications of a continued funding shortfall go far beyond just extra costs to patients.

Yusufzai told The New Humanitarian she knows first-hand how it goes.

In 2009, she helped open a 20-bed clinic in the Deh Sabz district of Kabul province. For more than a decade, her clinic received funding from foreign NGOs who paid for everything from staff wages to syringes and vials for the laboratory. All that changed in the summer of 2021, when the Taliban began quickly taking territory across the country.

Fearing for patient safety, Yusufzai’s team made the decision to temporarily shut the doors of the clinic. “We didn’t have the money to pay the salaries of doctors or to buy even basic lab equipment,” she explained. The clinic has not opened its doors since.

Throughout its 12 years of operation, the clinic had been reliant on financial assistance from different foreign NGOs. Once the international community cut its support due to the Taliban’s return to power, there wasn’t enough money to reopen. – New Humanitarian