Access to care in Afghanistan

CRIMEDIM has begun a collaboration with EMERGENCY NGO to carry out studies on access to care in Afghanistan, as part of a broader effort to conduct operational research and contribute to health system strengthening. Afghanistan has endured more than 40 years of conflict. Following the change of government on 15 August 2021, international assets were frozen, foreign forces withdrew, and diplomatic delegations were evacuated. The resulting economic and employment crisis, compounded by severe constraints in the procurement of drugs and supplies, placed an additional burden on humanitarian organisations to ensure the provision of essential services. These pressures further strained an already fragile healthcare system.

Within this context, the two organizations conducted two research project focusing on access to care in Afghanistan. 

The first project, conducted in 2022, was a mixed-methods study examining the main barriers to access to care in Afghanistan in recent years and how these barriers have changed since August 2021. The study was structured in three phases, combining qualitative and quantitative methods. Findings were drawn from the analysis of data from EMERGENCY’s facilities in 11 provinces, an interviewer-administered questionnaire completed by 1807 patients and caregivers across 10 provinces, and 43 in-depth interviews with EMERGENCY staff and hospital directors.

The second project, carried out in 2024, focused on Emergency, Critical and Operative (ECO) services in Afghanistan. It sought to capture both patient and provider perspectives on barriers to access, quality, and service delivery. Using a mixed-methods approach, the study analysed data from EMERGENCY facilities in 11 provinces, administered questionnaires to 1552 patients and caregivers as well as 32 EMERGENCY staff members, conducted 11 semi-structured interviews in government-run hospitals, and assessed hospital capacities using a modified WHO checklist (WHO Harmonized Health Facility Assessment) .

Drawing on the expertise of both partners, the studies revealed a decline in consultations in August 2021, with activity returning to pre-crisis levels as early as September 2021. More patients sought care for civilian trauma rather than conflict-related injuries. While patients reported feeling safer when visiting health facilities, their capacity to pay for care diminished after August 2021. Systemic challenges, including gaps in primary healthcare, uneven quality of services, shortages of trained personnel, and limited ambulance coverage, continue to undermine access and drive patients directly to tertiary hospitals, worsening congestion.

The findings on ECO services highlight significant deficits in health awareness, quality of care, staff training, and medical transport availability. Many patients fail to recognise warning signs or do not know where to seek assistance. As one chief surgeon in Kabul reported in 2024:

“People do not understand what certain symptoms mean or where they should go. So they go to the pharmacist, who acts out of economic interest. He gives something, but then the situation worsens and patients arrive at the hospital. […] We also have these so-called ‘doctors’ who are not real doctors, but pretend to be.”

Building on these insights, CRIMEDIM and EMERGENCY produced two advocacy reports (accessible here and here) and contributed to scientific literature, with further publications forthcoming:

Valente, M., Lamberti-Castronuovo, A., Bocchini, F. et al. (2024). Access to care in Afghanistan after August 2021: a cross-sectional study exploring Afghans’ perspectives in 10 provinces. Conflict and Health, 18, 34. https://doi.org/10.1186/s13031-024-00594-5 

Lamberti-Castronuovo, A., Valente, M., Bocchini, F. et al. (2024). Exploring barriers to access to care following the 2021 socio-political changes in Afghanistan: a qualitative study. Conflict and Health, 18, 36. https://doi.org/10.1186/s13031-024-00595-4