The war-torn South Asian country faces an additional issue of funding as it struggles to build its healthcare system.

Kabul, Afghanistan – In a recent address to Afghanistan‘s healthcare providers, Chief Executive Abdullah Abdullah said, “With what we spend on a single day of war, we could build a state-of-the-art hospital.”

With that statement, Abdullah – a medical doctor himself – summed up the state of healthcare in the country plagued by limited resources and an ongoing war.

Health facilities in Afghanistan have come under attack from armed groups. According to the World Health Organization, there were 34 reported attacks on healthcare facilities in the first quarter of 2019, killing at least nine workers and patients and causing the closure of at least 87 medical facilities.

War and poverty

Najmusama Shefajo, an obstetrician-gynaecologist who has worked in public hospitals and private clinics in Kabul and Helmand provinces, said it boils down to two issues: war and poverty.

“Four decades of war has led to increasing poverty, which has a clear effect on health,” said Shefajo.

“If a mother doesn’t have the money to eat properly or for proper medicines, then she can’t bring a healthy baby into the world and if her baby is unhealthy, it affects the entire community.”

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In her eight years of practice, Shefajo said she has come across only a handful of patients with reliable access to healthy, nutritious foods and quality medications.

This lack of access to nutritious foods and media reports of low-quality, fake or expired Pakistani and Iranian drugs have put more pressure on overworked and underpaid hospital staff.

Bariz Ahmadi, who has been working with government-run hospitals for the last three-and-a-half years, said a majority of doctors are forced to supplement their income by working after-hours at private clinics.

“On a single day, there will be at least 1,500 patients coming into a public hospital and at least 50 of them will be admitted to stay overnight. Yet a doctor’s salary is still not enough to cover their basic expenses.”

On average, a doctor working in government hospitals makes between 12,000-15,000 Afghanis ($151-$189) a month even as the Afghani continues to decline in value.

Ahmadi said while the Maiwand Teaching Hospital was only meant to admit enough patients to ensure that the staff could study different illnesses and treatments, a growing need forced them to admit more patients.

The hospital, which opened in the 1960s, was set up to treat between 300-400 patients a day, but the daily patient load often surpasses 1,000. This means doctors who are meant to treat an average of 30 patients a day end up seeing three times as many.

Two brothers from Tagab district of Kapisa province are treated in Kabul after they suffered adverse reactions from wrongly-prescribed medicines [Ali M Latifi/Al Jazeera]

Need for structural change

Afghan health workers say an overall structural change is needed in the sector. The doctors say they are often forced to use sub-standard equipment and even medicines for treatment.

“An Afghan doctor and a foreign doctor both studied the same thing, but the difference is in the equipment at their disposal … We have to do the most difficult procedures using some of the most basic tools,” said Shefajo.

One doctor, speaking on condition of anonymity, said since most of his patients were unable to afford their prescriptions, he collected expired medicines for them.

The doctor said even though he was aware of the adverse effects of expired medicines, he was left with little choice. “They need the medicines. So I tell them to be careful while taking them. It’s better than nothing.”

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A combination of lack of funds, equipment and an ongoing war means the health sector continues to be stretched thin as at least 1.9 million people find themselves in need of emergency medical services this year.

This has forced those patients who can afford to travel abroad, to go to Pakistan, India and Turkey for medical care. Afghans spend an estimated $300m a year seeking medical treatment abroad.

Malang, 52, has been coming to a government-run hospital in Wazir Akbar Khan for more than a year after he woke up one night, screaming in pain. But looking back at the cost, he wished he had gone abroad.

Doctors told him his right arm and right leg were paralysed. “I worked as a porter for years, carrying whatever people needed help with.”

While his condition has not yet improved, Malang said shuffling between hospitals cost him at least 40,000 Afghanis (about $500).

Working to feed his family of six girls, but lacking an education or a trade, meant Malang worked odd jobs making a few thousand Afghanis a month when times were good.

“My wife has to work in people’s houses now and I have become saddled with debt and still don’t know what to do.”

Recent advancements

However, some doctors Al Jazeera spoke to said despite the setbacks and resource crunch, Afghan health workers have made the best of a bad situation.

Dr Najib Sediqi, who began his work as an internal medicine specialist in Helmand, said he has seen some improvements.

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“I started my practice under the Taliban in Helmand. At that time, there was no difference between a hospital in Sangin [district] and Kabul,” he said.

Wahidullah Mayar, spokesperson for the Ministry of Public Health, said despite the difficulties, there have been advancements in healthcare.

In 2003, Afghanistan had the highest maternal mortality rate in the world – 1,600 of every 100,000 women would die during pregnancy. Today, that number has dropped to less than 300.

The child mortality rate has also been reduced by more than a half, from 160 of every 1,000 children not making it to age five a decade ago to nearly 50 today.

Mayar said these statistics were due to government-led efforts to address the nation’s health concerns, particularly over the last four years.

In 2018, the Ministry of Public Health signed a $3m agreement with the Telecommunications Regulatory Authority to link 15 provincial hospitals with hospitals in Kabul.

In the last four years, more than 420 health facilities were established in different parts of the country. This includes the nation’s first neurosurgery hospital, inaugurated in Kabul last year.

“There was a time where you could barely find an ultrasound machine in Kabul. Now every private clinic has at least one. People used to travel abroad even for an ECG [electrocardiogram], now we can do that in Kabul,” said Sediqi.