How Afghanistan and Nepal improved some health outcomes – even during war

Over the past 20 years, Afghanistan's Nangahar, Helmand, and Uruzgan provinces have seen some of the country's worst insecurity and conflict. Remarkably, they've also seen some of the strongest improvements in certain health outcomes.

“In my research in Afghanistan, I’ve found that some of the most severe conflict areas have experienced the greatest gains in access to vaccines and treatment of diarrhea and acute respiratory infection,” said Dr. Nadia Akseer, an Afghan scientist and epidemiologist, now serving as a scientist at Johns Hopkins Bloomberg School of Public Health, and Scientific Advisor to Exemplars in Global Health.

Research in Afghanistan and Nepal, both of which experienced long and violent conflicts, demonstrate that countries can improve health outcomes despite conflicts and suggest strategies health leaders may adapt and adopt to achieve health gains in other insecure settings.

Dr. Akseer highlights two key drivers that can help support health improvements, even in the midst of conflict: funding and local coordination and integration.

“The same conflict that makes certain provinces or areas dangerous for inhabitants’ health also makes them target areas for donors,” said Dr. Akseer. Donor resources can provide a cushion and even reverse the decline in access to health care and outcomes usually associated with insecurity and violence. “With the right resources, gains can still be made,” said Dr. Akseer.

Those resources need to be accompanied by increased community engagement, coordination, and awareness of health priorities. “Factions and groups in conflict can have conversations about the need to protect women and children’s health during the conflict,” said Dr. Akseer. “Often, NGOs will lead these talks, meet with the clashing groups and say, ‘We need to provide healthcare services to civilians.’ Those conversations can encourage gains in health outcomes.”

She added that NGOs "that deliver in high-conflict areas tend to have established relationships there. They work with communities, elders, and are integrated. This integration is core to protecting health services.”

This appears to have played a role in historic improvements to health outcomes during Nepal’s decade-long Maoist insurgency.

From 1996 until a peace deal in 2006, more than 12,000 people were killed, 200,000 internally displaced, and an estimated two million fled to India. At the same time, Nepal continued to make remarkable strides in human development – increasing immunization and education rates, access to clean water, and nutrition, while reducing infant mortality, stunting, and open defecation.

While limited evidence is available on how these gains were achieved during the conflict, Exemplars in Global Health research, which included a literature review and interviews with informants, indicated that the Maoists did not interfere with government health and education initiatives.

In fact, the “Maoists also started making people aware of their fundamental human rights and tried to persuade them on why they should fight to get their rights back,” said Raj Kumar Subedi, the former Monitoring and Evaluation Manager for the Nepal Public Health Foundation, and Exemplar’s in-country research partner for stunting in Nepal. “This could have increased the health literacy of community people and improved the utilization of primary health care services.”

The Maoist party’s commitment to health as a human right and a more accessible health system also served to pressure the government to demonstrate that it was already pursuing and implementing an egalitarian health agenda. As one Ministry of Health official told Exemplars research partners, “the communists had just come and they thought making everything free would help and we could not say no to [free facility-based deliveries].”

Several interviewees pointed out that both sides in the conflict made health care access a strategic priority, resulting in the expansion of services in several parts of the country during this period of conflict.

A ministry of health official involved in vaccination campaigns during the time described them to Exemplars in Global Health research partners as “conflict sensitive."

"If the government was going there and if the babies were being vaccinated, then the government soldiers did not do anything and the Maoists also did not do anything because their children were getting vaccination. So, we did not take anybody’s side and went to the villages as scheduled to give the vaccination and that worked. We did not give any details to them, we only recorded the child’s age,” the official said.

It is important to note that gains in conflict areas are still extremely difficult to achieve and often uneven. For example, innovative approaches like mobile health teams can help deliver immunizations, oral rehydration solution, and antibiotics, to reduce under-five mortality. But these mobile health personnel cannot help pregnant women trapped in their homes access the antenatal care or skilled birth attendants they urgently need.

“Health interactions that require people to access a functional health facility are harder to protect during a conflict,” said Dr. Akseer. Afghanistan’s high maternal mortality rate, which has declined from 1,600 maternal deaths per 100,000 live births to 400 – still among the highest in the world – illustrates the challenge of delivering time-sensitive, facility-based care in a conflict setting.

However, there are tools that can help. For example, community midwives can be trained to deliver antenatal care to help identify challenges early. When Afghanistan invested in training more midwives and expanded the number of midwives in the country from 211 to 3,333 from 2003 to 2013, skilled birth attendance shot up from 14 percent to 46 percent, helping reduce maternal mortality.

This had an important knock-on effect. Midwives, as a trusted local authority, were highly effective at encouraging women to go to a health facility to deliver at the first sign of complications, when such a facility was available and accessible. Births in health facilities increased from 13 percent to 39 percent during the same period. Similarly, Nepal’s Community Health Volunteers, scaled out nationally in 1992 with 20,000 workers and by 2017, with more than 50,000 workers, helped deliver family planning and maternal and child care despite ongoing insecurity.