How Afghanistan can protect its recent gains in health outcomes

Over the past 20 years, Afghanistan has made modest but noteworthy gains in health outcomes. Maternal mortality has been cut by about 75 percent, under-five mortality has dropped by half, and the prevalence of stunting among children under five dropped by about one third.

Dr. Nadia Akseer has spent much of her professional career investigating those gains. Born in a rural district in Nangarhar province, Afghanistan, during the Soviet invasion, she fled with her family to neighboring Pakistan before eventually emigrating to Canada. Dr. Akseer went on to a career as an epidemiologist-biostatistician working with Dr. Zulfiqar Bhutta at SickKids, and most recently at Johns Hopkins Bloomberg School of Public Health. She is also a research partner and Scientific Advisor to the Exemplars in Global Health program.

Exemplars News spoke with Dr. Akseer about how Afghanistan’s leaders could protect their country’s recent health gains, as news out of the country reveals that 2,000 of its 3,500 health facilities have closed.

Exemplars News: Over the past 20 years, despite ongoing conflict, Afghanistan has made notable progress on improving health outcomes. What does the research tell us about how Afghanistan's new government can protect those gains and continue to improve health outcomes? What other post-conflict countries might serve as good models?

Dr. Akseer: There's 20 years of data and evidence that shows what's worked and what's not worked in Afghanistan. Here’s what that data tells us: One powerful tool that the government can use to continue to improve health outcomes is contracting the provision of health services out to NGOs. These NGOs, such as Save the Children, have been in Afghanistan for decades and have an established relationship with the community. There are also national NGOs such as Care of Afghan Families or the Afghan Development Association. They may have better relationships with the communities because they are local and they know the language, context, and the culture. All of these NGOs can be funded directly to continue the delivery of healthcare. We need to work with these NGOs, because they're the only entity available in the community right now that can deliver health care services to the people of Afghanistan. Another tool for continuing the delivery of health services and protecting recent gains is ensuring that women are able to continue going to work, especially those who are working in health, and not just clinicians and physicians, but also public health workers. The government’s leaders need to consider that these essential providers directly affect the health of the women and children in their own homes. Ensuring that health workers get paid and can continue to safely go to work is also really important. If people are not getting paid, they're not going to go to work.

Exemplars News: Is lack of payment for health workers a new issue in Afghanistan?

Dr. Akseer: The payment of health workers is a crisis right now because there's no money, so people are not getting paid. This is one cause of the collapse of the health infrastructure. Even prior to the Taliban takeover, there were problems with health workers not getting paid. There were delays in their payments, because corruption is a really big problem in Afghanistan. There wasn't good transparency or accountability. The research on this is clear, health workers at all levels from midwives to specialized clinicians need timely and fair payment.

Exemplars News: What health gains are most at risk right now and why?

Dr. Akseer: I think everything is at risk right now. Malnutrition is a really big problem. Fifty percent of Afghan kids are chronically undernourished. This is a chronic problem, but now there is also more acute malnutrition or wasting of children because people don't have money to buy food and there's no food to buy. Now that vaccinations have stopped, what's going to happen? We don't need to hypothesize on how infectious diseases spread. We have evidence from all over the world, of what happens when kids don't get vaccinated. These diseases, they'll take off instantly. There's a huge risk of infectious diseases, even some of the ones that have been close to eradication in Afghanistan, like polio, taking over the country. Not to mention COVID-19, which continues to rage through Afghanistan. Women's health is also in danger of regressing. The maternal mortality rate in Afghanistan is already one of the highest in the world. Over the last 20 years, it improved from 1,600 maternal deaths per 100,000 live births to 400. But now these women have nowhere to go get care because the facilities are shut down. Of course, women’s empowerment has been a driver of health improvements in Afghanistan. The gains in child mortality, maternal mortality, and nutrition that women’s empowerment supported also look very fragile right now. When there's no functional health system, everything is at risk of falling apart.

Exemplars News: One of the biggest takeaways from Exemplars in Global Health research is the central role of political commitment and political stability on improving health outcomes. What does that mean for Afghanistan's leaders?

Dr. Akseer: The effect of political stability and peace on health outcomes has emerged in almost all of our Exemplar country case studies. That is a core finding. What this means is that for health gains to be made and to be sustained, we need to have some stability. It doesn't mean that the same political party needs to stay in power for 40 years. The government can change, but there need to be mechanisms put in place to protect whatever systems have been put in place in that country. The global research is clear, [and] the new government and NGOs working in the country really need to be thinking about how to maintain the health, food, and education systems and protect those from disruption at all costs.

Exemplars News: How important is stakeholder coordination for sustaining the health care progress Afghanistan has made over the past 20 years?

Dr. Akseer: Stakeholder coordination is critical. There are many different stakeholder groups in Afghanistan. The new government is one stakeholder group. Donors, current and past, are another key stakeholder group. I think the diaspora are another key stakeholder group. Afghanistan has the privilege of having a huge diaspora community. Then also the local civilians of the country, they're another stakeholder group. I think bringing these stakeholders together for a shared vision, and a shared plan. We've seen this approach help so many countries make remarkable gains in health outcomes. The one agenda, one plan, one health approach was core to the success of Ethiopia and Nepal in reducing stunting. In almost every case study, coordination around a common agenda was a core element. Usually, the government plays a key role in bringing the stakeholders together and coordinating their efforts, and saying, "Okay, this is our agenda. Let's see what role everyone can play." It sounds simple. It's obviously a lot more difficult to execute. We don't know if this government can do that or can see value in that. I think someone else, externally, needs to pull all the stakeholders together. Maybe we need to have a health-focused task force for Afghanistan, which includes health professionals and the stakeholder community; perhaps this falls to the diaspora to lead.

Exemplars News: That brings us to the next question: you're a member of the Afghan diaspora, what, if any, role can the diaspora play in supporting and protecting improved health outcomes? What does the research tell us?

Dr. Akseer: The research from Exemplars tells us that the diaspora can be quite important, for instance, in driving a reduction in stunting through remittances. In Kyrgyz Republic, Nepal, Senegal, Exemplar research, we’ve seen that those remittances are actually pulling households out of poverty. Beyond the money, coming together and coming up with a plan for re-engagement with Afghanistan, how can we with our skills and our experience that we have, what can we do to help the Afghan people? They need help in everything. Health, education, business, agriculture, finances, everything you can think of, they need help with that. The diaspora has an important role as an advocate to raise awareness about the issues. Talk about it as much as we can to whoever we can, whoever will listen. We can't let Afghanistan be forgotten.