Dangerous lack of respect for neutrality of healthcare providers by all sides is costing lives, says Médicins Sans Frontières

One in four Afghans has lost someone to violence in past year, says charity

Conflict has become so widespread in Afghanistan that one in four people have lost a relative or close friend to violence over the last year, a leading medical charity said.

The network of clinics and hospitals is also too small, weak and expensive to look after the victims of war and disease, and there, and there is a dangerous lack of respect for the neutrality of healthcare providers by all sides in the fighting, which is costing lives.

The findings appear in Between Rhetoric and Reality, a report by Médicins Sans Frontières on Afghanistan's medical system after a decade of international aid.

Government troops, their international backers and insurgents all periodically seize clinics for use as temporary bases, while ambulances and patients are delayed and harassed at Taliban and government checkpoints in violation of international law.

The government also plans to use medical centres as polling stations in upcoming elections opposed by the Taliban, further politicising buildings that should stay neutral. They will also risk damage should they come under attack from groups that have threatened to disrupt the election.

"Active fighting, the occupation of health facilities by armed groups, deliberate delays and harassment at checkpoints, and attacks on medical vehicles and personnel all create unacceptable barriers for sick or wounded people in need of medical assistance," the report says.

Nearly half of patients who make it to the four hospitals run by MSF in the north, south-east and central Afghanistan face fighting, landmines, checkpoints or harassment on the way, the charity's director, Christopher Stokes, said.

After a decade of foreign efforts to transform the country, hundreds of millions of dollars have been poured into everything from vaccinations to midwife training, but many Afghans say the programmes have brought little real change to their villages.

"The patients' testimonies expose a wide gap between what exists on paper in terms of healthcare and what actually functions," the charity says. It warned that money spent by commanders looking to "win hearts and minds", or as part of counter-insurgency techniques, often did not meet the most pressing needs of ordinary people.

"In our area the canals are half-finished, the school buildings are half-finished, the clinics are half-finished," one school principle from northern Afghanistan told MSF. "It means that we don't have proper healthcare in our area. A lot of doctors also escaped because of the fighting and insecurity."

The report also warned that although there had been progress since the fall of the Taliban, restricted access to the most violent and deprived areas has skewed data that seems to show dramatic improvement in conditions.

"Health statistics from Afghanistan are notoriously unreliable … data from the most insecure areas are often excluded," the report says. "This introduces a persistent bias that is likely to contribute to overly positive country averages."

The research was done over six months and included interviews with more than 800 patients. MSF provides all services free of charge, unlike government and private hospitals where official and unofficial fees can bankrupt families. Two-thirds of the people who seek help at MSF hospitals live in extreme poverty, with their families surviving on around $1 a day, the report says.