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Abstract
Introduction Existing health system challenges in Afghanistan were amplified by the Taliban’s August 2021 government takeover during which the country faced an evolving security situation, border closures, banking interruptions, donor funding disruptions and international staff evacuations. We investigated factors that influenced health sector and health service delivery following the takeover.
Methods We purposively sampled individuals knowledgeable about Afghanistan’s health sector and health professionals working in underserved areas of the country. We identified codes and themes of the data using framework analysis.
Results Factors identified as supporting continued health service delivery following August 2021 include external funding and operational flexibilities, ongoing care provision by local implementers and providers, health worker motivation, flexible contracting out arrangements and improved security. Factors identified as contributing to disruptions include damaged infrastructure, limited supplies, ineffective government implementation efforts and changes in government leadership and policies resulting in new coordination and capacity challenges. There were mixed views on the role pay-for-performance schemes played. Participants also shared concerns about the new working environment. These included loss of qualified health professionals and the associated impact on quality of care, continued dependency on external funding, women’s inability to finish their studies or take on any leadership positions, various impacts of the Mahram policy, mental stress, the future of care provision for female patients and widespread economic hardship which impacts nearly every aspect of Afghan life.
Conclusion Afghanistan’s health sector presents a compelling case of adaptability in the face of crisis. Despite the anticipated and reported total collapse due to the country’s power shift, various factors enabled health services to continue in some settings while others acted as barriers. The potential role of these factors should be considered in the context of future service delivery in Afghanistan and other settings at risk of political and societal disruption.
- Health policy
- Health systems
- Qualitative study
Data availability statement
Data are available on reasonable request.
This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
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WHAT IS ALREADY KNOWN ON THIS TOPIC
Afghanistan’s health sector faced multiple challenges prior to the Taliban takeover in August 2021, some of which were exacerbated by the regime change.
WHAT THIS STUDY ADDS
This study highlights specific factors that facilitated or thwarted functional adjustments to the new operating reality from the perspectives of individuals working in or on Afghanistan’s health sector.
HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY
Examining how health system implementers coped, adapted and sustained service delivery in the wake of Afghanistan’s 2021 crisis can elucidate which mechanisms and structures facilitate continuation of health service delivery and prevent disruptions during political shocks in fragile, conflict-affected and vulnerable settings.
Introduction
The challenges of delivering health services in fragile, conflict-affected and vulnerable (FCV) settings are myriad and significant.1 In Afghanistan, the health system has been characterised by fragmented and under-resourced services for decades.2 3 Under the previous Taliban regime, the healthcare system suffered numerous weaknesses with respect to the public health infrastructure, the availability of healthcare professionals and the accessibility of services.2 Only a few international entities including the United Nations and international non-governmental organisations (NGOs) were operating in Afghanistan at that time. The government’s health system relied on a contracting out model, with the Basic Package of Health Services (BPHS) implemented by externally funded NGOs in 31 out of 34 provinces beginning in 2003.4 The BPHS—with funding from the World Bank, the European Union and the US Agency for International Development—aimed to address urgent health needs arising from years of conflict and to swiftly provide essential services (particularly relating to maternal and newborn health, child health, nutrition and communicable diseases) to rural populations through NGO partnerships. During this time, significant improvements in healthcare delivery were made, with mortality among children under 5 decreasing by 29% between 2003 and 2015.5 Until June 2021, this contracting out model was under the stewardship of the Afghan Ministry of Public Health (MoPH) through performance-based partnership grants and performance-based partnership agreements,6 7 including the Afghanistan Reconstruction Trust Fund’s Sehatmandi Project.8 9
Following the Taliban’s government takeover in August 2021, the health system’s existing challenges were amplified by a rapidly evolving security situation, border closures, banking and donor funding disruptions and international staff evacuations.1 8 10 Delays in service provider contract renewals that existed prior to the government takeover heightened fears of widespread service interruptions,10 with both warnings and reports of health system collapse.10–13
On 20 September 2021, just 1 month following the Taliban takeover, The Global Fund agreed to sustain delivery of essential services across 2200 facilities in 31 provinces by providing an initial interim bridge fund of US$15 million through the United Nations Development Programme; subsequently the UN Emergency Fund allocated an additional US$45 million.14 15 To address the critical gap in hospital services beyond the scope of Sehatmandi, the UN and International Committee of the Red Cross injected emergency funding to cover operating costs.8 This allowed external development partners time to plan a transition from Sehatmandi to a UNICEF-administered Health Emergency Response project under the new circumstances.
Utilisation of primary care services not only continued in many areas during the months following the government change, but even increased compared with same time period the previous year.16 However, UN partners also estimated that more than 25 million people in Afghanistan needed humanitarian assistance by March 2022,17 and almost 29 million 1 year later.18 In this context, the demands on the health system and on those who deliver health services in Afghanistan continue to be immense.
In this study, we seek to understand and document how individuals and organisations responsible for delivering primary healthcare in Afghanistan responded to the systemic shock following the events of August 2021. Recognising the inherent difficulties of conducting research during such a tumultuous time, we also understood the value of understanding what happened from the perspective of individuals directly affected. We, therefore, asked these individuals to reflect on factors that likely minimised disruptions and facilitated adjustments to the new operating realities. Our findings provide insights for health policy-makers, development partners and implementers operating in Afghanistan as well as other FCV environments, where major power shifts may occur.
Methods
Sampling, data collection and analysis
We used a qualitative research design focused on in-depth interviews with individuals with knowledge of the state of healthcare delivery in Afghanistan following the Taliban takeover and the decisions taken by national and international health system actors following August 2021. We conducted in-depth interviews with key informants currently working at global, national or local levels (including one rural, heavily conflict-affected setting and one urban setting) as well as individuals who worked within the country prior to the Taliban takeover in August 2021—either for the MoPH or an implementing partner.
With respect to the specific settings selected, we focused on Kabul and Helmand Provinces. Kabul represents a diverse range of urban experiences, and most participants had extensive experience with the system at a macrolevel, encompassing both governmental and non-governmental institutions and policy implications. In contrast, participants in Helmand helped explain what happened to service delivery in a rural setting, including with respect to health facilities, professionals, dialogues, negotiations and other related issues.
The decision to use purposive sampling was informed by the uniqueness of the situation in Afghanistan and our research objectives. Our approach was primarily designed to address the specific nuances and challenges of studying the Afghan health system during such a pivotal moment. It was crucial to have participants who could shed light on both the macro (organisational) and micro (individual) level changes and decisions that transpired. Participants were selected by the authors based on the following criteria: (1) Relevance: their role and experience should be directly related to the Afghan health system during August 2021 and the months following the Taliban takeover; (2) Insight: Their ability to provide detailed and knowledgeable information about the health system dynamics and (3) Availability: Their willingness and ability to participate in our study. Given these criteria, we searched for a diversity of respondents that worked across the following sectors: international organisations, development partner agencies, healthcare professionals and healthcare administrators (table 1).
Criteria used to purposively sample participants
Using the WHO’s Building Blocks of Health Systems framework as a starting point,19 we created an Interview Guide (see online supplemental file 1) that enabled us to solicit participants’ perspectives on the status of the health system and health services following the regime change, particularly with respect to (1) service delivery; (2) health workforce; (3) information; (4) medical products, vaccines and technologies; (5) financing and (6) leadership and governance. Our main focus was on primary care services, particularly services that had been the responsibility of BPHS programmes prior to August 2021. While our interview guide contained key questions applicable to all, we tailored our probing questions to each individual. For instance, all were asked about crucial factors for continued service delivery. Subsequent questions then delved deeper based on the participant’s expertise and the ongoing discussion.
Supplemental material
The motivation for our methodological approach was grounded in the operational constraints of the time immediately following the August 2021 Taliban takeover. Given our own (ie, Princeton University’s) mobility restrictions with respect to travel from the USA to Kabul at that time, we elected to use remote in-depth interviews to hear directly from decision-makers, staff from implementing organisations and providers about what they were experiencing and witnessing.
Interviews lasted approximately 60 min each and were conducted using Zoom (audio only) by MB-R and AS between October 2022 and February 2023. Based on participants’ preferences, interviews were conducted in English (which both interviewers are fluent in), Pashto or Farsi (both of which MB-R is fluent in). All recorded interviews were translated (when necessary) into English and transcribed by an independently contracted firm. Field notes were transcribed if participants requested that the interview not be recorded (two interviewees). MB-R and ESD used an iterative approach guided by the tenets of framework analysis and an interpretivist research paradigm to analyse the data, starting with an initial coding framework, with ongoing refinement and analysis of themes as new insights emerged from the interview data. Framework analysis was considered to be an appropriate approach because it facilitates data analysis on applied policy research topics. The interpretivist research paradigm was considered appropriate because it aligned with our stance that we can only understand an individual’s reality through their experience of that reality, which may or may not be different from another individual’s, based on their own historical or social perspective. Throughout data collection, we recorded the emerging concepts and themes from each interview and highlighted new areas to explore with subsequent participants in greater detail as well as areas where consensus seemed to be forming. This interim analysis approach was instrumental in developing initial codes. Interviews continued until saturation was reached, that is, when we stopped hearing new perspectives across the emerging themes from additional participants.
Data were analysed within the qualitative data analysis software Delve (https://delvetool.com/). The initial coding was conducted by MB-R and ESD, with oversight from AS. Once the first round of coding was complete, MB-R and ESD reviewed the data, refined the codes and carried out a second round of coding. MB-R has over a decade of qualitative research experience and previously led a research firm in Afghanistan. ESD has qualitative research experience carrying out needs assessment interviews, key informant interviews and analysis for an international NGO. AS has extensive experience conducting qualitative research over two decades and received her PhD with a focus on qualitative research methods.
To improve the validity and reliability of our findings, we initiated our research with a comprehensive literature review, laying a foundational understanding by identifying knowledge gaps and framing our investigative questions within the broad spectrum of academic discourse. We ensured consistency in our data collection procedures, asking each interviewee the same core set of questions in a comparable setting while documenting any deviations. After transcribing the interviews, we undertook member checking, circling back to certain interviewees to validate our understanding of their inputs. Two separate researchers independently developed codes and all three researchers met to discuss and come to agreement on any discrepancies. Additionally, before formalising our manuscript, we presented preliminary findings to expert peers, welcoming their feedback and critique to enrich the depth and quality of our study.
Ethics
Each participant provided informed consent. Informed consent was taken verbally at the start of the Zoom call. For interviews that were not recorded, participants submitted a signed version of the informed consent form via email to the research team in advance. Additionally, the authors contacted respondents to inquire if they were interested in participating in the study, primarily through email and, for some, via WhatsApp text. The study received institutional review board approval from Princeton University. Participant identities were kept confidential and related data were stripped of personally identifiable information. Audiorecordings and transcripts were stored securely on password-protected computers, only accessible to the research team. Study methods and results are reported following the Standards for Reporting Qualitative Research.
Reflexivity statement
MB-R, from Afghanistan, has a decade of qualitative and operational research experience and has led numerous large-scale, health-focused research projects for international development partners in Afghanistan. ESD has worked with an international NGO supporting development partner-funded projects in the development space and has conducted qualitative research relating to migrant and refugee populations in Italy. AS worked in Afghanistan when she was employed by UNICEF’s Regional Office for South Asia and subsequently provided backstopping support to UNICEF’s Afghanistan Country Office when she was employed by UNICEF’s New York headquarters office. She has provided programmatic and technical support on a range of child health issues to other conflict-affected countries as well. Some of the participants were known to the research team prior to this study. More details are included in online supplemental file 2 reflexivity statement.
Supplemental material
Results
We conducted 20 key informant interviews. Participants spanned a variety of professional backgrounds, roles within the health system and locations (table 2). Participants included Afghans as well as international staff supporting health projects in Afghanistan.
Characteristics of key informants interviewed, October 2022–February 2023
Interviews revealed substantial variations in how health service delivery was affected by the fall of the Kabul government. Key themes that emerged relating to disruptions, the influence of governance and funding, and workforce resilience are summarised below.
Direct and indirect disruptions/changes to service delivery
Participants described factors that impeded or otherwise changed delivery and utilisation of health services following and even prior to the government change in August 2021.
Damage to healthcare facilities
Intensification of the conflict in advance of the Taliban takeover inflicted damage to health infrastructure in several areas of the country, and in some cases, the damage remained following the transition.
Especially during the summer of 2021, [our rural area] had a lot of destruction. Thirty-seven out of 87 health facilities were completely [destroyed]. In some cases, we did not have anything left except ruined buildings.
- National non-governmental organisation staff, male
After the fall, these [rural] hospitals were renovated, [but] not all the hospitals that were damaged. In some places the [district hospitals were] unusable because of the damage sustained when conflict intensified.
- Women’s/reproductive health professional group staff, female
Security
In communities that were previously heavily affected by conflict, the transition allowed NGO staff greater mobility and access and, as a result, health service delivery increased.
Before the fall, the Taliban already had greater control in Helmand, which is why there was always fighting between the government and Taliban forces. The conflict has stopped, which is one of the positive impacts here. In the past, vaccinators and other health workers would travel fearfully and avoid going deep into rural areas for safety and security reasons. But this is not a primary concern now.
- Health service delivery professional, female
Access to the health facilities—it has increased. Why is that? It’s because, first, the health facilities have been renovated and functionalized, and people can access … them. For the white areas [active conflict areas] where there weren't any health facilities in the past, now there are other mechanisms that are put in place to provide services, for example, establishment of mobile health and nutrition teams in different provinces.
- National non-governmental organisation staff, male
I have been to [community in a formerly conflict-affected] district. Nothing was working in those areas. The phone was not working. There was no clean water. The area was located far from the health facility. And we chose that area for [our work] because of its rural location. We managed to identify 29 similar sites that are located far from the health facilities. Women in these areas did not have access to basic services in the past.
- Women’s/reproductive health professional group staff, female
Widespread economic hardship
The severe financial strain that much of the Afghan population experienced after the Taliban takeover and the country’s associated banking problems meant that the population able to afford private health services declined. This resulted in a significant increase in utilisation of public health services, which in turn placed an additional strain on health service delivery.
The purchasing power of people has drastically decreased, and their first choice is to avoid visiting a private clinic. [Now] they instead go to a public hospital, endure all the problems, and wait for hours and days to avoid paying for the doctor’s fee. It is not that they don't seek quality or good care, but simply because they have to make tough decisions on what to prioritize since most people have lost their jobs or income sources.
- Health service delivery professional, male
Patients rushed to public hospitals, leading to increased patient loads and negatively impacting maternal health. For example, in [province], gynecologists were overwhelmed due to the increased patient load and the hospital’s lack of capacity to respond.
- Women’s/reproductive health professional group staff, female
Supply chain
In the early months after the Taliban takeover, participants noted that NGOs and other internationally funded organisations had sufficient supplies to continue providing routine care. However, stock issues emerged shortly thereafter due to uncertainties regarding imports and the inability of traders to make overseas payments.
We had enough in stocks, so we didn't run into any major challenges for the first few months after the fall. But afterward, the shortage started. The first five or six months were ok. Most of the suppliers had enough in their stocks. But after that, everything changed.
- Health service delivery professional, male
We are heavily reliant on imported products across all sectors, including health. After the fall of the previous government, the banking system was paralyzed, which restricted medical suppliers from sending money outside the country to purchase medical supplies. This issue was and still is a major bottleneck.
- Health service delivery professional, male
Loss of healthcare professionals
While participants lauded the dedication of Afghanistan’s health workers and the tremendous sacrifices they make to deliver lifesaving care under the most challenging of conditions, some also noted that the uncertainties health workers, and particularly female health workers, regularly face might drive them to leave the country.
Qualified and experienced staff are being replaced by new and inexperienced officials, such as replacing nursing managers with extensive experience with recruits who don't know the system. Such actions are bound to impact the health system negatively.
- Women’s/reproductive health professional group, female
In 2002 and ’03 and ’04, we did not have enough female health workers, particularly midwives and nurses. We had to sign an agreement with Tajikistan, and we brought lots of female nurses from Tajikistan to Afghanistan. They were actually providing services. I believe if this situation continues, we might end up with a similar situation that after three or four years, we need to ask neighbor countries to send us [female health workers].
- Former Ministry of Public Health official, male
Gendered impact
Reactions to, and experiences in, the new working environment varied for health workers based on their gender, context and exposure to social changes and restrictions after the fall of Kabul. Female health workers described some of the ways in which they have been disproportionately impacted.
I am done with the [medical] residency and only need to take the exit exam, but unfortunately, the Taliban have banned it until further notice. I was fully prepared and had studied for it. Today, I was supposed to be in Kabul for the biometrics.
- Health service delivery professional, female
There is a deliberate campaign to remove women from leadership positions in the health sector, especially in key decision-making offices. Women are also being removed from serving as technical board members where their voice is needed. The new policy requires that organisations with executive boards, technical boards, or advisory councils exclude women from their lists.
- Women’s/reproductive health professional group staff, female
‘The strange part and change I felt was that when I called our male colleagues, they would not answer. Everyone was afraid. But after a few tries, I was able to connect with a colleague and asked about returning to the office. They told us it was okay, but we had to wear an appropriate hijab. I told them that it really didn't matter to us because we were wearing the same proper hijab even before the Taliban took over.’
- Health service delivery professional, female
On 21 December 2022, when the Taliban banned women from working with NGOs across the country, the only sector that received an exemption was the health sector. While the exemption was not formally communicated, MoPH officials provided assurance to service providers. In return, service providers made changes to comply with the restrictions but this brought additional challenges. One common concern that emerged was around the Mahram policy, which requires female health workers to be accompanied by a male chaperone from their immediate family. While these restrictions were not new for health workers in some areas of the country, many highlighted the challenge of having Mahrams accompany health workers for long periods of time to remote areas where employment opportunities for the Mahrams themselves are limited.
Some rural areas lack access to essential services due to logistical, travel and operational challenges. Getting midwives to these rural areas is tricky because if they take their Mahram, they will have no job opportunities. For example, I recently spoke with a midwife in [X community] who said she works in a health facility, but her Mahram has been with her for over six months and has no job. He is caring for the house while she works at the health facility. This is a huge problem and challenge. If a midwife is deployed to a rural area, her children need access to school, and her male family member needs a job.
- Women’s/reproductive health professional group staff, female
Participants also highlighted the Mahram policy’s effect on the training of high-quality personnel, by limiting female health workers from opportunities to improve their technical skills.
We get picked up from and returned to our houses by the designated office vehicle. But that doesn't mean we don't have problems. Like in the past, we try to solve them. One major change is that previously we would have a technical team from Kabul evaluate our teaching by sitting in the class and closely monitoring how I teach and convey the course content. They would then provide feedback. But now that is not possible.
- Health service delivery professional, female
[Another] challenge is the relationships and the connections between Afghanistan and other countries because doctors need to develop. They need to, day by day, become updated, but a female doctor is not allowed to go outside of country, even for the purpose of study, or even for the three days without a man.
- Women’s/reproductive health professional group staff, female
With increased restrictions keeping female health workers from interacting with their male colleagues, participants described using digital technologies such as phone calls or WhatsApp messages to substitute for in person interactions. Participants also mentioned that their supervisors had preemptively put in place restrictive measures to avoid potential backlash by the Taliban regarding female working spaces.
Whenever we would go to a colleague’s office to talk about work, we would first text to make sure it was okay to visit. But we were instructed to try our best to solve everything via phone and avoid visiting offices because the Taliban might have their people watching our movements.
- Health service delivery professional, female
Beyond the operational concerns created by these restrictions, participants shared their reflections on the mental toll.
I see the challenge of the shrinking space for female health workers, especially as it relates to the southern region [of the country], and the motivational damage. I think every little infringement has a very deep psychological impact on health workers.
- International organisation staff/consultant, female
Safety has improved, but [there is a] psychological, constant psychological fear. I think the best way to say it: Before August 15, there was much more of the focus of women on physical survival. Now, I think it has shifted to psychological and emotional survival.
- International organisation staff/consultant, female
The first big challenge is that we don’t want to be the last generation of female doctors. We need another generation to come to study to develop and become female doctors. When schools are closed, when girls couldn’t even go to the school, how can I be hopeful that when I become retired, when I become old, there will be another female doctor to provide help for a female?
- Women’s/reproductive health professional group staff, female
Influence of governance and funding
Direct implementation by government
As stated above, contracting out through the BPHS programme was the predominant model of health service delivery in most of the country prior to the Taliban takeover. Participants indicated that in the early days following the fall of Kabul, essential service delivery in provinces outside the scope of BPHS—and therefore implemented directly by government—faced significant challenges. Participants who had been collaborating closely with the previous MoPH also reported disruptions due to restrictions with development partner funding.
At that time, we had a lot of funds for our department, for running, for monitoring, for ensuring all the activities, and for some additional support of capacity building. That was stopped [after the fall of the government]. That was stopped because there was some specific limitation that no one can financially support the [new] government.
- International organisation staff/consultant, male
Change of MoPH leadership and policies
The transition in national leadership resulted in new coordination and capacity challenges between international actors and the MoPH.
It is not a full engagement or maybe optimum engagement with the government. There is engagement at maybe a technical level, not above that. You can say that there is no discussion or joint discussion on how to move forward on how to strengthen the health system. There’s just a quick fix.
- International organisation staff/consultant, male
Having a meeting in the ministry was very different back then than it is now. Because now you're just dealing with people that simply do not understand the basics. And some of them are even doctors, but even the doctors that they have brought on board have political agendas, have religious agendas. So the technical aspect is just pretty much… it’s pretty much nonexistent.
- International organisation staff/consultant, female
As UNICEF assumed the stewardship role over the contracted out health system, development partners coordinated with the MoPH but without providing the Taliban with direct decision-making power. At the same time, the new government sought to establish its new leadership role.
The HER project was supposed to start from November 1st until December 31st [2022], but still there are struggles back and forth, and the Ministry of Public Health is not agreeing with certain decisions and some of the selections despite … them having their observers in the whole procurement process that was conducted by UNICEF. They disagree with some of the decisions, and that’s why there is no contract as of yet.
- National non-governmental organisation staff, male
They still behave like an anti-government element. They don’t feel responsible that they are the one to provide services for the people of Afghanistan. They are the ones that should facilitate the work of the international organisations, but they still put conditions on international organisations, “Give me this, this, this, this. Then I will allow you to go and vaccinate a child there.
- International organisation staff/consultant, male
When the discussion reached to a level, the [MoPH] issued a letter to all governors in the provinces. If the NGO does not have the authorisation from the Ministry of Public Health, they cannot operate in the province. Close them down. This was the extreme. I was witnessing this. In such a situation, how can you not engage the existing administration in decision making?
- International organisation staff/consultant, male
Implementing organisations have been challenged to adjust to the new policy changes and restrictions. Participants—even those with previous experience working in Taliban controlled areas—described additional bureaucratic hurdles and delays as a result of Taliban efforts to closely control health operations at a local level.
We had to renew our memorandum of understanding between the NGOs and the Ministry of Public Health. Also, now for every project, regardless of who funds this, we must seek a no-objection certificate from the Ministry of Public Health. Unless we have such a certificate in hand, we will not be allowed to start our operations and the project implementation at the provincial level. This is a big challenge, and it is really delaying things.
- National non-governmental organisation staff, male
At times local NGOs found themselves negotiating sometimes opposing instructions from development partners and authorities on the ground. One participant argued that trust-building between development partners and local NGOs is critical to enable NGOs to be effective in navigating the complex environments in which they operate.
In most cases, we found negotiating a path forward with donors harder than with the local authorities. I don’t blame them. They were under strict instructions. However, to get things done, moving beyond rigid guidelines and prioritising whichever approach ensures improved outcomes is necessary.
- National non-governmental organisation staff, male
Flexibility of contracting out arrangements
Once funding for the health system resumed, the existing structure of health service delivery through contracting out arrangements facilitated the transfer of responsibilities and stewardship. With development partners no longer routing funds through the MoPH and Ministry of Finance, the contracting out system meant that bridge funding could be routed directly from multilateral donors to UN agencies, who then paid implementing NGOs to continue providing services.
What was good was that the Global Fund and the UN continued with the same system. They continued using NGOs—many of the same NGOs. They continued with the same package of services that had been delivered before. They continued with many of the same ways of paying. Not completely the same but making sure that there were sufficient payments and such. We were able to transition the system across three different financing modalities without causing too much disruption on the ground as it [otherwise] might [have].
- International organisation staff/consultant, male
I think one is that, as you know, [essential health services were] being provided by NGOs from the very get-go, ever since the early 2000s. It was [therefore] much easier …to shift … financing away from the government and directly to the NGOs or indirectly to the UN institutions. That was a major reason why…the system was able to be resilient and carry on.
- International organisation staff/consultant, male
Performance-based monitoring
Participants had differing views on the role of pay-for-performance systems in supporting continuation of service delivery despite uncertainty within the health system. As one participant stated, ‘[Because] payment is linked with performances, the NGOs are trying to maintain or sustain those performances, the utilisation of services. That’s one of the [reasons] that the utilisation has not been affected as much as it may have been expected.’ This view was tempered, however, by a key informant who believed that such a system incentivizes inflated performance reports.
We do need to incentivize these indicators. [However,] if we incentivize, we give incentive to produce fake data. I agree with the concept of performance management, or pay-for-performance, but pay-for-performance requires specific capacity to be able to monitor.
- International organisation staff/consultant, male
External funding and operational flexibility
The Afghan health system’s reliance on external development partner funding and the risk that this poses to the availability of services in the face of shifting global priorities was evident following the Taliban takeover.
Our service delivery… is very much donor dependent. All the payments—the salary payments or the running cost—everything was paid by the donors. When they announced that they’re not going to support the service delivery anymore, so all of us—so everything stopped.
- International organisation staff/consultant, male
Even today, if UNICEF stops, everything will stop. It’s not sustainable at all. It hasn’t been sustainable in the past. We don't have any other financing mechanisms in place. There is no insurance mechanism. I can't expect those to happen even now because we are not in a stable country.
- National non-governmental organisation staff, male
With many international actors reluctant or unable to engage directly with the Taliban administration, the UN was mandated by Security Council Resolutions 2596 and 2626 to engage all parties on humanitarian issues and lead discussions on the way forward for the health system.20 21 Participants described actions taken to mobilise development partners in the early days after the fall of the previous administration.
We had lots of meetings at that time, and the only message that we wanted to convey to the World Bank was that, “Please don’t [stop] funding at least the health sector.” Even if this is now under the umbrella of the Taliban, but the services are for people. We started advocating for that one, so [there were] lots of publications, [including several] arguing that the health sector is non-political and should be seen completely separate from the context of the politics of Afghanistan, and donors should continue.
- Former Ministry of Public Health official, male
It was a chaotic situation, and the whole health system was on the verge of a collapse. NGOs started advocating. First of October, we had a commitment from the UNDP to resume funding the health system.
- National non-governmental organisation staff, male
While bilateral and multilateral development partners were negotiating solutions to the funding freeze triggered by the Taliban takeover, other internationally funded implementers were able to continue.
We are not under the same rules and regulations, which obviously gives us the flexibility. For us, I don’t even think for a moment, I was like, Oh, my God, what if … we end up … stopping the services? That simply did not happen.
- International organisation staff/consultant, female
Workforce resilience
One of the most critical factors supporting continued service delivery in post-August 2021 Afghanistan has been the commitment and resilience of the health workforce itself. We explored the reasons behind this commitment as well as strategies they have used to manage their new realities.
Continued care provision
Even during the immediate crisis, local implementing organisations continued providing services in many settings.
The services did not stop. It was operational in the district centers and rural areas. I know for sure [that of] the 78 health facilities that I was responsible for, operation did not pause. Only in a few health facilities where the midwives were shaken and had left the health facilities without informing their supervisors, the service delivery was disrupted. Services in the rest of the health facilities were unaffected.
- Women’s/reproductive health professional group staff, female
These NGOs who are running the health service delivery, who are providing the services, they were used to this with the Taliban. They were working in all provinces where the rural areas were governed by them, by the Taliban in [the] past 10 or maybe 15 years.
- International organisation staff/consultant, male
Some implementing NGOs continued service provision when external health funding paused and the fate of service delivery implementation contracts remained uncertain. Similarly, many health workers continued working, despite not being paid to do so and, in some cases, despite risks to their own personal safety.
Health workers were not new to running out of supplies. They were not new to not getting their salaries. For them, it was just business as usual but with the additional sort of mental insecurity about, “Oh my God, they're saying that there will be no more funds.”
- International organisation staff/consultant, female
[Starting even before the Taliban takeover,] we didn’t receive our salaries for three months. Despite the lack of pay and the escalating conflict, we continued our duties… When the police station was targeted, the effects of the explosion were felt in our office, causing broken windows. We huddled under the tables, shaken with fear as we sought refuge. Despite these extreme conditions, we still showed up to work but were not paid. The salaries for those three months were ultimately written off.
- Women’s/reproductive health professional group staff, female
Motivators
Health workers in Afghanistan have long shown strength and resilience in the face of challenges, including during the long-standing conflict prior to August 2021.
The oath we took with our conscience—and God perhaps—gave us the determination to work in crisis situations and face numerous restrictions, including family limitations. We remained firm and fearless. A pregnant colleague in her eighth month of pregnancy would still show up to work as a Reproductive Health officer on a BPHS+project. When the window glass shattered during an attack, I quickly ran to her and held her in my arms to calm her down. I pulled her towards me, just as the broken glass barely missed her.
- Women’s/reproductive health professional group staff, female
In the aftermath of the Taliban takeover, the role that providers played (despite uncertainty regarding their contracts and many months of missed pay) was critical to continued health service delivery. Female health workers faced additional challenges due to fears regarding new policies and restrictions that the Taliban would implement. One participant described what she did to motivate female health workers to continue in the days following the change in government.
I went to the Ministry and, in front of the Taliban’s health commission and through the media, called on midwives and nurses to return to work. I emphasized that we work for the health of mothers, children, and the community, not for governments, which gave the nurses and midwives some reassurance and confidence to return to their jobs.
- Women’s/reproductive health professional group staff, female
This sentiment was echoed by other key informants who discussed feelings of patriotism, duty and responsibility towards their communities as underpinning the reason health workers continued working.
I lived under the previous Taliban regime and saw how difficult it was to access good care. As a medical professional, I take an oath to serve, no matter the circumstances. So, it was time to put my beliefs into practice. That said, I was anxious and afraid of what would happen to me and my family and friends.
- Health service delivery professional, male
Believe me, they didn’t have anything to eat. They were on night duty. The hospital couldn’t provide them anything to eat. They didn’t have salaries, but among all of these things, these women stayed committed for the other women, [they knew they] were providing help to them.
- Women’s/reproductive health professional group staff, female
As a health worker living in a village, you cannot see a child is dying of a disease and you know how to manage it, and then you don’t do it because you don’t receive your salary. It’s a moral responsibility for them.
- Former Ministry of Public Health official, male
In addition, some healthcare providers may have felt pressure to return to work in order to meet specific pay-for-performance metrics and ensure future compensation, or to ensure clients for their private practices.
In the P4P, there was some conditions. … If they’ll not achieve, they will receive 50 percent of their budget, and 20 percent will be cut from their fund. It is for motivating them to do the best job and improve the performance.
- International organisation staff/consultant, male
This is a reality that when someone—nurse, doctor, technician—is working in a public health facility, there is a referral system [that] exists between their private practice, and their public practice. If they don't go to the public hospital, that will affect their private practice as well.
- International organisation staff/consultant, male
A few participants also noted that, for many providers, there was no other viable option than to return to work following the government takeover.
They have to live in this country. They have to work, to continue, to not lose their job, their contract with the government. Because of this—they came and they were providing services for the pregnant women and the children, and at the maternity hospital they were working and providing services during that very bad situation, bad time.
- International organisation staff/consultant, female
Some of these health workers were owed their backpay for months. I think it was a mixture of commitment to the cause and perhaps, probably, also hope that in the future they would get paid and the work they put in now would get reimbursed in the future, as well.
- International organisation staff/consultant, male
Some will answer ‘We are Afghans, we love our country, we stayed.’ But I look at it this way: what other option existed for them to leave? They went to work hoping to get paid. By going to work, maybe they had a forty to fifty percent chance to get paid. But staying at home, this chance reduced to zero.
- International organisation staff/consultant, male
Discussion
The study was undertaken during a period characterised by immense challenges. The operational landscape for international organisations in Afghanistan was ambiguous, with many organisations questioning whether or how to respond to rapid developments following the Taliban takeover.
In this complicated context, our study methods were subject to several limitations. We collected qualitative data based on in-depth interviews with individuals actively engaged with the Afghan health system immediately before and after August 2021. While our networks and knowledge of the context allowed us to purposely sample individuals who could offer rich insights into the decisions and dynamics during that pivotal phase, it is possible we would have obtained different inputs from other individuals had we expanded our participants. A related limitation is that we only interviewed one former MoPH official, no former healthcare workers, and a notable omission in our sampling was the non-inclusion of current MoPH officials. Since operational responsibilities in this sector had shifted mainly to UNICEF, our participant selection prioritised those most involved in that transition. Nonetheless, our questionnaires did incorporate queries about participants' interactions with current authorities.
A further limitation created by our sampling technique (particularly snowball sampling), was that this may have created some biases regarding the types of individuals we interviewed. This relates to the point above regarding the lack of current MoPH officials. In addition, snowball sampling sometimes creates challenges with respect to transparency but we did not obtain recommendations for specific individuals to interview from existing participants; rather we obtained recommendations regarding potential types of individuals (eg, development partners) and then identified specific individuals through internet searches and other professional networks. In addition, for the two interviews that were not recorded, we may have lost some information using only field notes.
Additionally, we decided to focus our research on primary care delivered by local NGOs through subcontracting systems because of our desire to focus on a sector where service provision continued after the governmental collapse. We acknowledge that the findings of this study may not be generalisable to secondary and tertiary care, or to healthcare delivery provided directly by the MoPH. Further, our interviews did not yield data on health information systems, one of the six building blocks in the WHO framework we used to develop our interview guide.
In spite of these limitations, our study findings suggest that the Afghan health sector presents a compelling case of adaptability in the face of crisis. Despite the anticipated10 22 and reported11 23 total collapse of the health system due to the shift of power, various factors enabled services to continue within the country. First, because NGOs were largely responsible for delivery of essential health services prior to the government takeover, development partners were able to contrive a stopgap solution to the crisis of legitimacy of the Taliban government. The dedication and motivations (some altruistic, some financial) of front-line health workers also enabled services to continue in some settings during the transition.
Other studies have reported that public health service utilisation continued and even increased in some settings following the Taliban takeover.16 24 25 Participants in our study corroborated this, attributing increased utilisation to improved security, shifts from private to public services due to economic hardship and reduced ability to afford private health services. As noted elsewhere,26 participants in our study also highlighted factors that hindered health service provision following the government takeover: poor infrastructure (particularly in severely conflict-affected areas) and challenges procuring essential medicines and supplies from outside of the country.
It is interesting to consider the stark contrast between the health sector and service delivery under the previous Taliban regimen (which was extremely fragmented with very low capacity), and the current situation. The importance of recognising—and using—the existing capabilities of Afghan professionals, programmes and systems was highlighted as critical at the time of the takeover.27 Indeed, the current MoPH has largely retained its prior capacity with respect to staff and has continued to collaborate with international organisations. These are positive features that can be leveraged to support further health system strengthening.
Our findings suggest several implications for future service delivery in Afghanistan and other FCV contexts at risk of political and societal disruption. First, contracting out can be an effective service delivery model to continue health services during a government shock in such settings. Contracting out is already common in many low-income and conflict-affected countries, although an important critique is that the quality and consistency of care provided by different service providers can vary,28 as can the accountability and sustainability of health services when external support wanes and the government is unable to sustain operations through the national budget.29 30 Additional concerns include that these approaches hinder efficiency,31 government capacity building32 and even the quality of care.33 Monitoring and evaluation activities are key to mitigate these potential problems.34 The extent to which it is preferable—and feasible—to concurrently build government institutional capacities while investing in contracting out activities should also be considered.
Second, strong collaboration across partners resulted in the rapid resumption of health services in a relatively tumultuous but short period of time35 and likely saved many lives. In FCV settings experiencing shocks—whether due to political turmoil or health emergencies—multipartner, inclusive coordination with clear roles, sufficient resource and leadership is critical for robust preparedness and response.36
Third, flexible and agile development partner protocols and guidelines are crucial to success in FCV contexts.5 The situation that unfolded after the fall of Kabul was highly unpredictable and erratic. With the reduced presence of international development partners, NGOs had to engage with the new authorities to navigate the changed implementation landscape, establish trust, negotiate access and seek permission to resume activities. However, local actors’ ability to do these things is influenced by the degree of decision-making power conferred to them. Such an approach centres on fostering trust and rapport with local authorities, ensuring access to hard-to-reach areas, and mitigating the impact of personnel or leadership changes that may occur following a shift in power on programme activities.
Fourth, the agility of the Afghan health sector to continue operations in the aftermath of Kabul’s fall suggests that it may have a role to play as a conduit for wider humanitarian efforts, for example, relating to nutrition, water, sanitation and hygiene, food assistance and agriculture. International donors, policy-makers and aid organisations can prioritise the health sector as an ‘entry point’ for conversations with regimes regarding broader humanitarian efforts, capitalising on the sector’s sanctity and neutrality.
Fifth, as the interviews demonstrate, the central role that local health workers played in maintaining health service delivery cannot be overstated. Such resiliency in the face of crisis has been reported elsewhere.37 In Afghanistan, their ability to adapt in response to evolving restrictions and their commitment to providing care in the most challenging of circumstances endured despite funding interruptions, operational constraints and a growing mental toll. This last challenge was perhaps particularly acute for female health workers who have seen their operational space shrink, as restrictions on women’s employment, education and use of public spaces increase. With these challenges potentially pushing female healthcare workers to leave the country and a new generation of female healthcare workers prevented from pursuing a medical education, questions remain around what the future of Afghanistan’s maternal and child healthcare workforce will look like. This was seen as a major issue of concern immediately following the Taliban takeover,38 and it has continued to this day.
Despite the evidence of health service delivery resilience in Afghanistan, extraordinary challenges remain. Decades of conflict have imposed a significant toll on health infrastructure and significant investment is required to improve operational capacity. In addition, support for health services at the local level varies, posing challenges for health workers who must navigate conflicting guidance from authorities, development partners and implementers. Importantly, there are significant and increasing challenges for female health workers, while bans on female education call into question the future of the female health workforce. This compounds the concerns surrounding the loss of trained and experienced providers more broadly. Finally, the profound economic crisis in which the country finds itself increases the pressure on public healthcare systems and the need for immediate humanitarian responses across all sectors. In this context, it is logical and fitting for development partners to finance essential services, through the Afghanistan Reconstruction Trust Fund, as part of the broader humanitarian effort. This support will not only ensure the continuity of vital services but will also serve as an incentive for the Taliban government to seek out and allocate necessary funding for secondary and tertiary healthcare services.
Future research should aim to determine which specific investments are most critical to ensure the provision of quality health services, particularly in the most disadvantaged settings of the country, as well as which opportunities to facilitate more sustainable, institutionalised approaches within the health sector in Afghanistan should be prioritised. Such evidence could help shape future implementation strategies for effective engagement and enduring resilience in the health sector within Afghanistan as well as other FCV contexts. Given the highlighted challenges around coordination with the de facto Taliban government and the relative inexperience in development partner relations of many of their officials within the MoPH, future research could also aim to examine strategies for engaging with the Taliban authorities around public health topics and best practices for facilitating engagement with local authorities in similar fragile and conflict-affected settings.
Conclusion
Afghanistan’s health sector, along with other sectors in Afghanistan, faced multiple challenges even prior to the change in government in August 2021. Some of these challenges were exacerbated by the country’s regimen change but this study highlights several factors that facilitated functional adjustments to the new operating realities. In navigating challenges in FCV contexts like Afghanistan, innovative, bold and evidence-based solutions to sustain health service delivery must be pursued. Such solutions should integrate robust financing and monitoring, political dialogue and engagement of government, as well as engagement at local levels in order to ensure quality care and effective reach to the most vulnerable communities.
Data availability statement
Data are available on reasonable request.
Ethics statements
Patient consent for publication
Ethics approval
This study involves human participants and was approved by Princeton University's Institutional Review Board #14818. Participants gave informed consent to participate in the study before taking part.
Supplementary materials
Supplementary Data
This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.
Footnotes
Handling editor Seema Biswas
Contributors The initial coding was conducted by MB-R and ESD, with oversight from AS. Once the first round of coding was complete, MB-R and ESD reviewed the data, refined the codes and carried out a second round of coding. All three authors contributed to the development and revision of this manuscript. AS accepts full responsibility for the work and/or the conduct of the study, had access to the data, and controlled the decision to publish.
Funding Funding was provided by the Center for Health and Wellbeing at Princeton University (no award/grant number). Weiting Wang and River Reynolds provided research assistance. Anonymous expert peers reviewed and commented on our preliminary findings. We are grateful to all participants for their willingness to share their experiences and perspectives with us, and to our publication peer reviewers whose inputs greatly enhanced this manuscript. Publication fees were supported by the Princeton University Library Open Access Fund.
Competing interests None declared.
Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Provenance and peer review Not commissioned; externally peer reviewed.
Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.