TRAPPED
Between
Rhetoric
And Reality
AFGHANISTAN
war
poverty
mortality rates
politicised aid
CONFLICT
35 years of war
2001 US led intervention
2014 violence continues
Surge in civilian deaths
Humanitarian needs grow
POVERTY and HEALTH
1/3 below poverty line
Women: x 100 more likely to die giving birth
Children: 1/10 die before five years
Underestimations
AID as AMMUNITION
Win ‘hearts and minds’
Threat based, not needs based
Blurred Boundaries
Selective Storytelling
Fails the
most vulnerable
“Best Performing” Reconstruction Area
“Best thing the US did in Afghanistan”
Exuberant claims
Veil
Spin
OBJECTIVES
Clearer picture:
access to
healthcare
Understand
barriers:
Types
Extent
Impact
METHODS
Study period: Jun – Oct ‘13
Cross-sectional survey:
800+ patients,
caretakers
LOCATIONS
DATA COLLECTION
Questionnaires, 763 : structured, pre-tested
Individual interviews, 35: semi-structured
Focus groups, 12: semi-structured
Additional information:
- MSF medical reports
- Key interlocutor interviews
ETHICS
✓ MoPH permission for survey
✓ Informed oral consent
✓ Confidentiality
✓ No identifiers
Formal review not sought
RESULTS
Deadly combination of barriers
Prevent
Delay
1 in 4
people
experienced
violence
VIOLENCE
7 in 10
barrier to reach MSF
n=763
4 in 10
conflict as a barrier
DISTANCE
Perilous Journeys
1 in 3
Taking wounded to
Kunduz  distance
a major difficulty
COSTS
2 in 3
Poor, extremely poor
$1 day
Household spending/week
People per household
Total cost previous illness
$54
11
$41
Medical costs previous illness $32
1 illness episode

costs more than
1 month of income
2 in 5
44%
forced to
borrow money
or sell goods
to obtain healthcare
during a recent illness.
HEALTH SYSTEM GAPS
Rise in
Numbers
Too Few
4 in 5
Bypass
Proximity
≠
Access
✗ quality
✗ availability
Staff
Services
Treatments
“empty, lacking medicines, qualified staff, and electricity,
closed, long queues, corruption, malpractice, high prices, no
referral“
PARTIES TO THE CONFLICT
Active fighting
Occupying
facilities
Deliberate delays
Harrassment
Attacks,
medical vehicles,
personnel
Sharp increase
in military intrusion
450 health facilities
close - insecurity
“I can’t go to the government doctor in
my area because of the insurgents and
other problems. They don’t like us to go
to clinics supported by the government.
If I go there, maybe the insurgents will
arrest me, ask me why I was there,
what I was doing there.”
- Male, 22 years, farmer, Nawzad district, Helmand
EFFECT
1 in 5
Death
LACK OF ACCESS
to medical care
DEATH REASONS FOR LACK OF ACCESS TO CARE
JOURNEY 36%
COST 32%
CONFLICT 18%
“In the last years violence has blocked us
coming to health centres and hospitals more
than 100 times.
The fighting doesn’t stop when there are
injured people. So we wait, and then they die,
and the fighting continues.”
- Male, 25 years, school principal, from Baghlan province
LIMITATIONS
Health facility survey
Underestimate barriers
Urban v rural bias
Responder bias
CONCLUSION
Far from a
simple success
story
Remarkable gap – paper and practice
Serious, often
deadly, risks
Neutral, needs based
Pragmatic, principled
Reality, not rhetoric
Meaningful medical care not available
Uphill struggle
THANKS
Ilham
Shahab
Kamal
Benoit deGryse, Renzo Fricke, Catherine Van
Overloop, Mit Philips, Tom DeCroo, Silvia Pineda
Corinne Baker, Jehan Bseiso, Jonathan Whittall
Thank you