Dr. Wahid Majrooh is acting minister of public health in Afghanistan, and he faces two looming challenges: leading the country's COVID response and maintaining health-care services in the wake of the Taliban takeover in mid-August.
The COVID situation is daunting: over 150,000 cases and 7,000 deaths so far.
The overall health-care picture is critical as well. To prevent the Taliban from gaining access to aid money, the World Bank and other international aid organizations suspended $600 million in funding, including support for the Sehatmandi project, which paid salaries for 20,000 health-care workers at 2,800 facilities across the country. Because of the suspension in funds, more than 2,000 of these facilities are shutting down, leaving the Afghan people bereft of care, both because of the inability to pay staff and the general lack of funding for health-care resources.
Health workers are in short supply too. Many have left the country. And women, who are a major part of the force of community health workers, at first stayed back from work, fearing violence and Taliban retaliation. Half of Afghanistan's 20,000 community health workers are women. On August 28, in the face of crippling staff shortages, the Taliban allowed all 2,000 women health-care workers to resume duties.
In this uneasy limbo, Majrooh, who joined the ministry in 2015 and assumed his current position in January of this year, discussed the health-care picture in a phone interview with NPR.
This interview has been edited for length and clarity.
Can you give us a sense of how Afghanistan's health-care system is now faring?
We are on the verge of collapse.
Our health-care system is very dependent on foreign aid. In 31 of our 34 provinces, primary health-care solutions are contracted to non-governmental organizations (NGOs). The ministry is not directly involved in providing these services. The World Bank and other international donors have frozen all funding. There is no clarity either about when this funding will resume. One of the main issues we're facing is that the donors have opted to not channel funds to Afghanistan at this time. They have sidelined the Ministry of Public Health as well, even though we've collaborated for years.
And that's because they don't trust the Taliban – even though the officials are the same as in the pre-Taliban government?
They justify [the freeze] with their own perception that the ministry is part of a system that they don't recognize at this date. But if communication is not sustained now, then it will have an impact on our dealings in the future as well.
How many doctors have left the country in the past month?
It is difficult to be able to present a figure, but the brain drain has been immense across the provinces. In just the region of Herat where I live, I estimate that at least 45 to 50 doctors and nurses have left.
Most health-care facilities across the country are now running out of emergency medication, medical oxygen and other essential supplies. The freeze in funding has affected over 80% of our health-care facilities. There is no money to run operations. Staff salaries haven't been paid even several months prior to the takeover as a result of violence escalating in provinces, creating more health-care issues, and we've dealt with three waves of COVID with a fourth wave coming.
What are the consequences of a health-care system that is choked by growing demand, lack of funding and staff shortages? What kinds of procedures might not be available?
Every day 150 mothers require Caesarean sections, half of these emergency cases. Both mother and child are at risk of death if complications arise. We perform 500 surgical procedures every day, half of which are emergencies. Those interventions will suffer, leading to more deaths.
How will it affect children?
With increased conflict, 20,000 children are at immediate risk of malnutrition, deprived of nutrition from aid programs and lacking basic health care.
What are the health-care priorities right now, given the constraints you're under?
The situation is very stressful at the moment. We're in an unprecedented time where there are many priorities. Our main concern is to ensure the availability of health-care staff and of supplies and financial resources. And then we need to be able to ensure the safety of our staff members from violence and attacks as a result of the ongoing unrest. We need the disrupted services to resume as soon as possible.
How about government-run hospitals?
Government-run hospitals are in bad condition too — even worse than aid funded facilities — as a result of the conflict and lack of funds.
What are the steps that you're taking in this situation?
We're coordinating with [international] NGOs and donors, describing the challenges that our health-care workers are facing and trying to suggest ways in which funding can be resumed. We're conveying our sense of emergency to the Taliban to prepare for the transition to a new ministry. I hope it will happen smoothly and swiftly.
How has the Taliban treated you and your staff so far?
I am coordinating with the Taliban Health Commission [made up of public health officials they have appointed to oversee health care]. Overall, the communication has been good. It will take time to rebuild the trust among health-care workers and to remove the fear that has set in, especially since health-care personnel appointed by the previous government believe that they will be soon replaced [by Taliban-appointed staff].
Are you optimistic about the transition, especially for female health-care staff?
How do you define optimism at this point in time? Well, sometimes in life, you're left with just one option and I'm in that phase right now. As long as we can ensure that our (female) staff can continue to work and that women and children [who are at the bottom rung of the societal ladder] are being cared for, I'm optimistic. If I am hesitant and doubtful now, it won't help anyone, and people in need of care will be the first to be affected.
How are international aid agencies faring in Afghanistan now? What is their situation moving ahead?
The ICRC has assured me they will continue their mission [in Afghanistan] and their focus is on emergency care. The Bill and Melinda Gates Foundation have assured me that they will continue funding some of our health-care facilities. I wrote to [international] donors two days ago, thanking them for two decades of support and proposing certain solutions on how we can overcome this [funding] freeze. I understand the limitations, but there are solutions that we can implement to make this possible. Otherwise any gains we have seen, especially in maternal and child health, will be lost. Afghanistan's health-care system still needs investment and support for at least one or two more years to strengthen its capacity before the government can take over.
What kind of solutions have you proposed in the wake of the funding freeze?
International aid organizations can be paid through different channels – either directly (by governments and aid donors) or through U.N. agencies.
Are you concerned for your safety or worried about retaliation by the Taliban as you speak out on the current health-care crisis?
I'm aware of the risks, but my focus right now is not on the political situation. I have no intention to stay on as health minister, and I haven't sought to challenge anything. My focus is ensuring a smooth transition so that life-threatening disruptions in health care and threats to personal safety [for health- care workers] are minimal. It is taking longer than I expected, however, and I don't know when a new ministry will be appointed.
How does all this make you feel?
It is very stressful and exhausting; we've lost a lot of sleep. We are really tired.
Kamala Thiagarajan is a freelance journalist based in Madurai, India, who has written for The International New York Times, BBC Travel and Forbes India. You can follow her @kamal_t.
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