Conflict and social determinants of health: would global health diplomacy resolve the Afghanistan healthcare conundrum?

ABSTRACT

Public health, conflict/war, Social Determinants of Health (SDHs) and Global Health Diplomacy (GHD) are believed to be strongly interwoven. Afghanistan that is known as the ‘Graveyard of the Empire’ has been passing through a very critical phase given the prolonged civil war during the last couple of decades, wherein the ongoing current situation further pushed the country towards the collapse of the political and economic systems. Thereby, Afghanistan’s healthcare system has been entrapped into the civil war conundrum causing the SDHs to be seriously affected. Conflict in any form, i.e. local, regional, or international, has left black swan impacts on not only the SDHs but also led to health crises given the inaccessibility, unaffordability, and more of lack of the infrastructure, and exodus of trained medical staff and healthcare inequity. In this situation, it is anticipated that GHD could play a significant role in providing equitable healthcare to people at stake. Against this backdrop, the focus of this paper is; how the SDHs have been impacted by the civil conflict and how the public healthcare has been turned into a conundrum; would the GHD resolve the healthcare crisis in the prevailing scenario?

KEYWORDS:

• Afghanistan
• Taliban
• conflict and civil war
• global health diplomacy
• social determinants of health
• healthcare

Introduction

While wars devastate physical and human capital, the impacts of war on GDP per capita remain unknown and unclear. This ambiguity results from how national income accounting treats the deaths and property destruction caused by war The manufacture of weapons and munitions is counted in a positive way, but the killing of people and destruction of property are not taken into account. The reduction of unemployment and shift of people from family formation and other non-market activities to wartime production can increase GDP per capita (Higgs, 2006, pp. 5–6). Conversely, war can lower GDP per capita by decreasing investment in new physical and human capital, as well as reducing the output of existing physical and human capital. Trade gains from both domestic and foreign trade can also impact the GDP per capita.

In fact, empirical evidences on war’s impacts on GDP remains mixed. Barro (1991) claimed that coups and political instability slow the GDP growth. In addition, Barro and Lee (1993) found that war has little impact on growth. Even so, Murdoch and Sandler (2004) found that civil wars slow the rate of GDP growth per head. By all accounts, the people of Afghanistan are at a tipping point as a result of the ongoing war there. Due to the country’s poor economic health, many people were forced to relocate, essentials were withheld, poverty and unemployment were rampant, all of which negatively impacted the Social Determinants of Health (SDHs). Therefore, Afghanistan is not in position to provide healthcare facilities to its citizens. The conflicts had left devastating impacts on the daily lives, health, and well-being of civilians caught up in conflict (Grono, 2006, p. 624).

It is seen that War damages healthcare accessibility and quality by reducing healthcare workers, destroying healthcare infrastructure, and disrupting multilateral lifeline supply chains. As a part of GHD, nonetheless, the need to protect medical care in conflictual situation is enshrined in international humanitarian laws, which are enforced through the humanitarian principles like medical impartiality and neutrality. Human rights and medical ethics apply in times of war as well as in times of peace. The World Health Organization’s Constitution (1948), demonstrated that health is a fundamental human right and that living in conditions that result in poor health, as well as being denied access to health care, are issues of human rights. As the former United Nations (UN) Secretary General (Kofi Annan), in his farewell speech (2006) remarked that the maintaining human security is also a top priority for WHO. He spoke about the interconnectedness of the security of all people, the global community’s responsibility for everyone’s welfare, respect for the rule of law, and the accountability of governments for their actions (United Nations Secretary General, 2006). These multilateral institutions used to pursue global goals like Universal Health Coverage (UHC), and the pledge to leave no one behind as in the larger context of GHD. However, despite several mechanisms in place in terms of GHD, the Afghanistan human suffering has become unavoidable during the ongoing conflict; rather, the risk of collapse is looming and hovering over.

Singh and Chattu (2021, p. 282) have argued that GHD is used to use for facilitating the provisions of medical healthcare during times of health crisis particularly during the ongoing war/conflict. These authors also quoted the WHO, wherein, the GHD is used to enhance health protection and public health to improve relations between states and a commitment by a wide range of actors to work together to improve health and achievement of fair outcomes that support the goals of poverty reduction and equity etc. According to same scholars, the GHD can be pursued through the diseases detection and preventions, as well as responding to health emergencies and issues by providing training to the grants in aids for medical training, medicines, promoting healthcare capacity-buildings etc.

Afghanistan conflict

Afghanistan’s reputation as the ‘Graveyard of Empires’ stems from the country’s unfortunate history under foreign rule, and the current situation with regard to the withdrawal of the United States and NATO only strengthens this view. The ongoing conflict was begun in 1978 with the Saur Revolution (Agwani, 1980, pp. 557–573). The conflict began when the former USSR intervened in the country (1979–1989) (Khan, 1991). The Soviet Army backed the ruling People’s Democratic Party of Afghanistan (PDPA) against the Afghan Mujahedeen. The US, UK, China, Egypt, Germany, Pakistan, and Saudi Arabia all backed them. The Soviet Army finally gave in and left the country in 1989 (Cornwell, 2010). During the revolution, Nur Muhammad Taraki (1978–1979) led the Communist Party to power.

The reforms were initiated by President Nur Muhammad Taraki’s administration and the same reforms deemed too radical by the various tribal groups and thus became unacceptable and unpopular among the Afghan people. The Communist Government (1978–1979) brutally suppressed all the opposition leaders, including unarmed civilians who opposed the government. It spawned numerous anti-government armed groups. Likewise, the incumbent communist government was split into two groups. This resulted into the political instability by dividing the government into two groups; Taraki led the first group, while his assassin, Hafizullah Amin, who became Afghanistan’s President, led the second. When the 9/11 allegations were levelled against Al-Qaeda in Afghanistan, which was believed to be responsible for the attack, the ongoing conflict was turned into an international war (Singh et al., 2021). The 9/11 attack, which was purportedly carried out by Al-Qaeda and which effectively turned the conflict into a war, had led to the US and Afghanistan adopting direct belligerent postures.

Given the Taliban’s direct support to Al-Qaeda, the US sought to depose them from power. The Taliban, on the other hand, had refused to extradite Osama bin Laden unless evidence for the same was not provided. It eventually resulted in Operation Enduring Freedom (OEF). Al-Qaeda and the Taliban were the targets of the Global War on Terrorism (GWOT). The International Security Assistance Force (ISAF), led by NATO, was established by the United Nations Security Council (UNSC) Resolution 1386 in December 2000 to combat the Taliban and Al-Qaeda. The ISAF has also been asked to train the Afghan National Security Forces (ANSF). In the Afghanistan War (2001–2014), the ISAF remained on the ground. The direct war ended with the death of Osama Bin Laden. The US, on the other hand, had decided not to leave Afghanistan, but rather to remain engaged in a more aggressive manner under the Trump’s South Asia policy. President Biden announced that the United States would withdraw its troops by September 2021 (Ryan & DeYoung, 2021).

During the ongoing war, an Afghan’s individual life has been characterised by human rights violations, atrocities, a lack of health and human security, lack of employment opportunities etc. Almost all sectors have been severely impacted, but health and its social detriments have emerged as one of the most critical areas seriously impacted by the conflict/war. In such circumstances, how can transnational justice be ensured in terms of healthcare, health security, and, most importantly education etc.? Stone (2020, pp. 544–545) has observed that in order to end the ongoing civil war and terrorism in Afghanistan, a number of international organisations, as well as major powers such as the United States, Russia, China, Iran, Pakistan, Qatar, and India, have made a number of efforts to bring peace in the country, however, all these endeavours remained in vain.

Afghanistan war and healthcare

Some scholars (Barro & Lee, 1993; Barro, 1991; Grono, 2006; Higgs, 2006; Murdoch & Sandler, 2004) have argued that war had drastic impacts on economy. Economy is backbone of all-around development. Afghanistan has suffered on part of war during the last couple of decades; hence, its economy has suffered seriously. Afghanistan’s healthcare system has been consistently deteriorating and it has been frequently referred to as one of the world’s ‘inferior’ systems (Aljazeera, 2016). As a result, Afghanistan is classified as having ‘low human development’ and is ranked 169^th out of 189 countries in the United Nations Development Programme (United Nations Development Programme, 2021). Abdullah Abdullah (Afghanistan’s Chief Executive) in one his addresses in 2016 to the country’s healthcare providers that, ‘With the amount of money we spend on a single day of war, we could build a modern hospital’. He had summed up the current state of healthcare in a country that is plagued by limited resources and a long-running war.

Since the Taliban era in Afghanistan began in 1996, nearly 18 years of intermittent warfare had wreaked havoc on the country’s infrastructure and economy (Laub, 2014, pp. 4–5). Despite the fact that healthcare received only a fraction of the national budget, the system remained under-funded, under-resourced and under-equipped. Although fundamentalist in nature and prohibitive in approach, the Taliban’s rule effectively put the health sector out of order (Strong et al., 2005). A contributing factor to the inadequate state of healthcare facilities was that women were denied access to such facilities. In addition, female health care professionals were not permitted to work, maternal mortality increased dramatically as old-fashioned notions of ‘modesty’ took precedence over medical intervention; only 1/3 of Afghanistan’s districts had access to a maternal or child health clinic etc.

In the post-Taliban era, the Afghan government has made significant efforts to rebuild the healthcare system, which has primarily relied on foreign assistance due to the country’s struggling economy and lack of technological expertise. An investigation conducted by the World Health Organization (WHO) in 2019 discovered that foreign donors provide the vast majority of the funding for the Afghan Ministry of Public Health (MoPH), which receives 4% of the national budget (Blanchet et al., 2019, p. 374).

For the last two decades, the Afghan government has been relying on international donors to finance basic services such as healthcare. However, Human Rights Watch noted that donor support has been declining for years and is precipitously continue to do so. In the short term, the Afghan government has limited capacity to move towards self-sufficiency and international donors fund 75% of its budget. In 2020, the country’s sustainable domestic revenue increased by 2.8% over 2019, owing largely to the economic downturn caused by the Covid−19 pandemic.

Social determinants of health

According to one study by Braveman and Gottlieb (2014), the social determinants of health are those economic and social conditions that differentiate an individual and/or a group/s in terms of health status differences. Furthermore, social determinants for those health promoting factors in which once living and working conditions influenced disease or the only ability to disease or injury, rather than risk factors. The distributions of social determinants can be shaped or reshaped by public policy that reflects the countries or regions prevailing political ideology (Mikkonen & Raphael, 2010).

The world has been divided into rich and poor countries in the present scenario, particularly when the pandemic has been at its peak. Inequalities and inaccessibility in health have characterised this division. Globalisation has had significant impacts on social determinants in terms of healthcare facilities, according to the researchers (Labonté & Schrecker, 2007, p. 5). The inferences posited that globalisation has created drastic unequal impacts on various facets of life and resulted in uneven distribution of power and wealth both within and across national borders, seriously affecting healthcare facilities support the above-mentioned argument (Labonté & Schrecker, 2007, p. 3). The Organization for Economic Cooperation and Development (OECD) has highlighted major differences in healthcare indicators such as infant mortality, life expectancy, disease incidences, death from injuries and even among the developed countries. The WHO argued that, ‘This unequal distribution of health-damaging experiences is not in any sense a “natural” phenomenon, but is the result of a toxic combination of poor social policies, unfair economic arrangements where the already wealthy and healthy become even wealthier, and the poor who are already poorer and bad politics’ (Commission on Social Determinants of Health, 2008).

It is said that assessing and comprehending the determinants of healthcare inequalities could become a key policy guide for global healthcare equity, accessibility and affordability. Of course, one approach to understand the social determinants of health care issues is to look at them from a geopolitical perspective. The population, healthcare facilities, job security, housing, transportation, poverty, and the population’s most significant health inequalities are all important elements of social determinants, according to this framework (Marmot & Wilkinson, 2006). On the other hand, commercial and corporate factors have an impact on health behaviours like smoking and consuming sugary foods (Kickbusch et al., 2016, pp. e895-e896). Some studies have also found that a variety of social factors have an impact on health outcomes, and these contexts are referred to as eco-social determinants of health status (Krieger, 2012, p. 939).

Governments, public policies and interests of countries, geographies, and most importantly, bilateral, regional, and multilateral engagements in international relations constituted the geopolitical determinants of healthcare (Persaud et al., 2018, p. 782). Analysis and understanding of the geopolitical determinants is important in this context because it allows us to identify individual health outcomes as products of national policy at the local or original level, whereas on the other hand at the international by the geopolitical determinants. The analysis may also help in recognising and identifying policies influenced by geographical factors, leadership, and, most importantly, bilateral, regional, or multilateral relations with neighbouring countries, as well as the distribution of required healthcare resources. As a result, accounts of geopolitical factors and issues have become one of the most important approaches to comprehending healthcare concerns, issues, and determinants. The example of migration would be very helpful in this context to understand this augment and perhaps perspective (Link & Phelan, 1995, p. 85). Migration has been considered an important element and determinant of an individual’s mental health because it is shaped by geopolitical factors such as civil war, ethnic conflict, war, colonisation, climate change, and treatment of minorities (Bhugra, 2004, p. 247). Understanding geopolitical determinants and citing migration as an example emphasises the importance of comprehending healthcare issues. As migrants interact with local social determinants such as employment and social support, especially during times of adversity and education, they find themselves in a conflictual situation, which can lead to chronic stress and adverse health effects.

Violence is another one of the important key health determinants in terms of social and geographical determinants (Bhavsar et al., 2020, p. 631). As a result, identifying and recognising state violence, as well as physical and sexual interpersonal violence, should be considered potential key indicators for healthcare system strengthening. In light of this, preventing and responding to violent conflicts between and within countries would have significant and positive consequences for violence reduction, public health, and public mental health policies.

Conflict/War’s impacts and the Afghanistan’s SDHs

Conflict/war is/are a major factor/s that can drastically affect the economy or economic growth of stakeholder country (Besley & Persson, 2008, pp. 522–530; Rodrik, 1999, pp. 387–388). Concomitantly, some scholars (Marsden & Samman, 2001, pp. 24–25) have argued that Afghanistan closely resembles to the model of a war-torn society and even economy as well. Following the near-collapse of its political system, it is displaying all of the characteristics of economic including the macroeconomic decline. Except for the military, government spending has decreased across the board. As a result, household entitlements have been impacted negatively.

Since the beginning of the Afghan conflict, the violence has been devastatingly affecting the Afghanistan economy and consequently healthcare as well. For example, the war diverts resources from productive to destructive activities. It results in two-fold losses; first, the economy of Afghanistan has been suffering losses because of the resources that supposed to put in welfare schemes and the modernisation, training and equipping the healthcare professionals are rather being diverted to security purposes. Moreover, Afghanistan withstands the worst of the damages in terms of loss of economic growth, foreign aid, foreign investment, human rights violations; losses of medical neutrality, impartiality etc. The conflict causes the lower fiscal revenues, which further limit the government’s capacity to spare the budget and fund for the basic public services to its citizens in terms of healthcare and basic necessities. According to the IMF, the conflict-related violence in Afghanistan had reduced the annual national revenues by around 50% in 2016. In comparison with 2005 levels of violence, this amounts to around roughly $1.0 billion (Af70 bn) (Mishra, 2021).

As per the World Bank, 2021 report Afghanistan’s economy is being characterised by fragility and reliance on foreign aid given the ongoing conflict. Conflict has caused political instability, weak institutions, socio-economic insecurity, insufficient infrastructure, widespread corruption, and a difficult business environment and constrained the economic growth and diversification. Concomitantly, the financial inclusion and access to finance are constrained by weak political and economic institutions, with credit to the private sector accounting for only 3% of GDP.

Scholars like Bayer and Rupert (2004, p. 703) have argued that war or conflict has drastic impacts on the flow of trade and this argument is well proven in the Afghanistan case as well. In the Doing Business Survey 2020, Afghanistan has been ranked 173^rd out of 190 countries. Along with the weak competitiveness contributes to a structural trade deficit of around 30% of the GDP, which is almost entirely financed by grant inflows (CNBCTV18, 2021). With the taking over by the Taliban, grant aids in terms of financial and health would likely to be affected, and it is being viewed serious threat for the SDHs as grants continue to finance approximately 75% of government spending. Mishra (2021) has argued that the security expenditures (national security and police) are high in 2019, at around 28% of GDP, compared to the low-income country average of around 3% of GDP. It has resulted in total public spending of around 57% of GDP.

It is anticipated that the economic condition would likely to become worse than the previous ones. Notably, the country’s annual public expenditure of $11bn is far greater than its modest revenues. The international grants cover the difference in costs, which amounts to about 75% of the total public expenditure. It had been experienced that when in the past, aid has been cut off; it has had negative impacts on Afghans’ on SDHs. When the United States cut civil aid in 2013/14, the overall poverty rate rose by 3%, the unemployment rate for Afghan men tripled, and 76% of the rural jobs created in 2007/2008 were lost. The number of people living in poverty increased by 5 million from 38.3 to 55% between 2012 and 2017. This rise in poverty coincided with a gradual reduction in aid flows, from around 100% of GDP in 2009 to less than 42.9% of GDP in 2020, resulting in employment and income reduction (Cordesman, 2019). Despite other factors such as growing insurgency and political instability contributing to the slump, the Afghan economy grew at a meagre 2.5% per year between 2015 and 2020, since the foreign aid has been started dwindling. According to the latest World Bank data, 2021, Afghanistan is one of the poorest countries of the world, and only six countries including Burundi, Somalia, and Sierra Leone, have a lower GDP per capita than Afghanistan.

Notwithstanding the deployment of the US/NATO troops, a number of vulnerable groups have been remained consistently susceptible on part of the Taliban. Given the Taliban’s ideology in terms of regressive, orthodox, and downright extremist, the women and school going girls have been remained the soft targets. This argument became more perceptible and validated when the Taliban’s targeted women in the media, judiciary and education (Alizada & Ferris-Rotman, 2021). Concomitantly, the human rights of various ethnic minority groups, including Hazaras, Hindus, Sikhs, Shia Ismaili, Shias etc. have always been at risk especially during the regime of Taliban. The communities have historically been persecuted and dominated by Sunni majorities, and terrorist groups in Afghanistan continue to target-specific religious and ethno-religious minorities (Afghanistan 2020International Religious Freedom Report, 2021).

According to some scholars (Van Egmond et al., 2004)), education is one of the major determinants of maternal health in Afghanistan. Higher education has been linked to increased health-care utilisation, birth spacing, and empowered women. According Bartlett et al. (2005), p. 93% women who were died as a result of maternity-related causes were illiterate. Whereas on the other hand, Ahmed et al. (2004, p. 223) demonstrated that less than five per cent of pregnant women in western Afghanistan had never attended school. According to one another study, Egmond et al. (2004) found that 64% women who participated in the reproductive health survey in Kabul’s capital city never attended a regular school and 62% were illiterate. Rahmani et al. (2015, pp. 71–85), whereas on the other hand, have claimed that the number of years spent in school has a significant impact on the healthcare.

Patriarchal societal practises such as early marriage and the requirement to obtain husband permission to receive health care all have a significant impacts on women’s health in Afghanistan. According to one study, Ahmed et al. (2004) conducted in rural western Afghanistan found that about 47% of women used to become pregnant before the age of sixteen. According to Van Egmond et al. (2004, p. 270), 93% of women said they needed permission from their husband or a male relative to seek professional health care. It is also argued that there is a correlation between the husband’s employment, household income, the woman’s economic activity, and the woman’s health. Van Egmond et al. (2004, p. 271) argued in their study that there is a significant correlation between the husband’s ‘qualified regular job’ and the woman’s use of family planning, antenatal care, and delivery at a Kabul health care facility. Contrastingly, Mayhew et al. (2008, 1851) has revealed a positive correlation between household income/wealth and the health care utilisation of women.

Numerous studies have identified food insecurity, a lack of safe drinking water, and a lack of latrines, as are the population’s primary concerns. In a 2002 study conducted in western Afghanistan, it was learned that investigated districts lacked protected water sources and adequate faeces control (Amowitz et al., 2002, p. 1286). The survival and development of Afghan children depends on clean water, basic toilets, and good hygiene. Children under the age of five die from diarrhoeal diseases more frequently than acute respiratory infections in Afghanistan. Diarrhoea and stunting are the result of these problems. Afghanistan’s stunted children outnumber their healthy peers. It is estimated that more than 67% of Afghans now have access to clean drinking water from ‘improved drinking water sources’. When it comes to toilets and latrines, only about 43% are improved and safe, meaning they separate human waste from contact hygienically. Children and their families remain at risk due to open defaecation in Afghanistan (UNICEF-Afghanistan, 2018).

Collapse of the health system: global health diplomacy as a panacea?

Soon after the withdrawal of 2021 and taking over by the Taliban along with notwithstanding of the GHD by many global stakeholders, Afghanistan healthcare system has not been sustained, rather reached to the lowest ebb and more precisely one can say as the collapse of the system (Schnell, 2021). Former Afghan Health Minister Wahid Majrooh in an interview with EFE claimed that country’s public healthcare system is on the verge of collapse in weeks or perhaps a month (Thiagarajan, 2021). According to Filipe Ribeiro, Afghanistan representative for Doctors without Borders (Medecins Sans Frontieres, or MSF) has claimed that the Afghanistan’s overall health system has been understaffed, underequipped, and underfunded and, moreover, the significant risk is that this underfunding will persist in the coming time. The same kind of views of echoed by Necephor Mghendi Afghanistan’s Head of the International Federation of the Red Cross and Red Crescent (IFRC). He argued that the healthcare system was already fragile and heavily reliant on foreign aid, and given the ongoing war kind of situation and the same would likely to come under more strain, given the international donors such as the World Bank and the European Union frozen the funding to Afghanistan (WION Web Team, 2021).

Thereby, the hospitals struggle to pay for basic medical supplies, they begin charging for items that were previously free. Many patients are unable to pay or even afford transportation to a health facility that may be quite a distance away. Certain key indicators, such as prenatal care access and skilled birth attendance, are stagnating or reversing. Women and girls face significant obstacles in obtaining even the most basic health and family planning information. Modern methods of contraception remain unmet and prenatal and postnatal care are frequently unavailable. The majority of modern cancer and fertility treatments, as well as mental health care, are unavailable. Routine preventive care such as pap smears and mammograms are almost unheard of, and a significant proportion of births continue to go unattended.

Resolving the Afghan health crisis?

In the globalised world order, healthcare crisis can no longer be addressed locally; rather, an international response is required. After a long and destructive civil war in Afghanistan, the health infrastructures needed to be rebuilt. The destruction and dismantling of infrastructures, emigration of the doctors and nurses, dwindling of the economy, resulting into poverty, unemployment, and ultimately seriously affecting of the SDHs had resulted into the serious health crisis in the country. Even some studies have been argued that service delivery and, in some cases, the complete disappearance of services have been happening. Therefore, it is said that the basic Package Of Health Services (BPHS) and an essential package of hospital services (EPHS) were developed by the WHO and through this health services are delivered by partners and the Ministry of Public Health (MoPH)’s innovative methods developed (Newbrander et al., 2014, pp. S8-S9).

World Health Organization (WHO) provides funds to expand the coverage and improve health quality, technical assistance and complementary financial support. The WHO has played a very monumental role to improve and expand the healthcare facilities in Afghanistan. As the co-chair of the Development Partners Forum (DPF), WHO assisted the MoPH and partners in strengthening policy dialogue, programme coordination and resource mobilisation? It has encouraged the creation of a new UHC health package for Afghanistan; contributed to the National Health Strategy 2016–20; launched SEHATMANDI 2018–21; encouraged the Afghanistan Health Minister to chair a Health Sector Strategic Oversight Committee; the creation of a fourth round of NHAs; the first Afghan Medical Council was strengthened; bolstered the National Medicines and Health Regulatory Agency; provided patient safety programmes in 17 hospitals; updated the National Medicines Policy (NMP) and Health Regulatory Authority (HRA); Developed the National Civil Registration and Vital Statistics (CRVS) strategy and tools for hospital International Classification of Diseases (ICD) implementation; created mobile health teams in 12 provinces to better serve nomadic populations; created PPPs to provide basic reproductive health and immunisation services in six insecure provinces etc (World Health Organization, 2021b).

The WHO-MoPH Joint Programme in which the WHO has been assisting the Afghanistan government in implementing the National Health Policy 2015–20 and the Country Plan 2018–2019. Universal Health Coverage is a goal of the 2016–2020 strategy, with a particular focus on universal access to primary health care. The WHO co-chairs a vibrant Health Development Partners Forum, assisting the Ministry of Public Health with coordination of all key stakeholders, to increase and guide the overall health resource envelope and improve the effectiveness of the health system presently made investments (World Health Organization, 2018).

The ‘Sehatmandi Project’ has been partnered by World Bank, the Afghanistan Reconstruction Trust Fund (ARTF), the World Health Organization (WHO), and UN, the European Union, USAID, and Canada. The Global Financing Facility for Women, Children, and Adolescents (GFF) has contributed $35 million to the project. The GFF aims to accelerate progress on reproductive, maternal, newborn, child, and adolescent health and nutrition in low- and lower-middle-income countries, as well as to strengthen financing and health systems for universal health coverage (UHC) (The World Bank, 2020).

Sehatmandi Project is being managed by the MoPH. Throughout Afghanistan, the Sehatmandi Project has been providing the high-quality health care, nutrition, and family planning services. Contracting out health services to nongovernmental organisations (NGOs) incentivises a focus on health outcomes, particularly for women and children, through a pay-for-performance approach. The project is assisting in the improvement of basic health and essential hospital services, strengthening the health sector’s overall performance, and increasing demand for critical health services.

The World Bank (WB) on behalf of 34 donor partners funding up to 30% of the country’s civilian budget and supporting government core functions. Since 2002, ARTF has provided assistance through national priority programmes, resulting in some of the world’s fastest progress in reducing infant mortality and increasing children’s school enrolment (ARTF, 2021). The project’s main results are still very important today. From 2017 to 2019, there was a 28% increase in the number of people who accessed basic health, nutrition, and population services. In 2019, health facility visits per capita reached 2.1, equating to more than 60 million individual visits for health, nutrition, and population services. Between 2018 and 2020, over 4,073,000 children were immunised. For 10 of 11 payment indicators, the volume of services delivered under the Sehatmandi project has increased (Andersen et al., 2021). For instance, between 2018 and 2019, the number of couple-years of contraceptive protection provided by Sehatmandi facilities increased by 49%, while the number of women giving birth in a health facility increased by 29%. Between 2003 and 2018, the new-born mortality rate decreased from 53 to 23 per 1,000 live births. The number of operational health facilities increased nearly fivefold from 496 in 2002 to more than 2,800 in 2018. Between 2006 and 2018, the under−5 mortality rate decreased from 191 to 50 per 1,000 live births, while the proportion of facilities with female staff increased. Between 2003 and 2018, the proportion of births attended by skilled health personnel increased from 14.9% to 58.8% among the lowest income quintile (World Bank, 2020).

United Nations Children’s Fund (UNICEF) has been supporting the MoPH at the national level in developing and implementing the community-based newborn care. It includes the provisions of effective interventions at the community level, such as zinc and oral rehydration solution co-packs for diarrhoea treatment. The UNICEF continues to advocate for a multi-sectoral approach to primary health care (PHC) by assisting the government in developing a costed national community health roadmap and advocating for an integrated package of community health services that includes primary health care, nutrition, hygiene promotion, polio, and child protection (UNICEF: For Every Child Afghanistan, 2021).

India has been one of the major donors of reconstruction aid to Afghanistan since the Taliban regime’s demise in 2001 since then; it has aided in the reconstruction of hospitals, provided medicines, and trained Afghan doctors (Embassyof India, Kabul, Afghanistan, 2020). The Afghan government announced its intention to expand access to high-quality healthcare in August 2019. In response, three Indian health organisations signed contracts with an Afghan health company under the Ministry of Public Health for a total of US$6.5 million (Tolo News, 2019).

The protracted conflict had seriously affected the healthcare system of the countries. Merelli (2021) has revealed that currently the Afghanistan’s healthcare system is one of the most precarious in the world. Given the conflict, the country’s life expectancy is standing at only 42 years; rather it lags behind the rest of the world in almost all health indicators. This argument is further substantiated by the fact of matter that it is having one of the lowest physician-to-population ratios (30 per 100,000 people), as well as hospital beds (40 per 100,000 people) and nurses (20 per 100,000 people). This is considerably less than the global average for South Asian nations, which continue to be among the least developed. Only 11 doctors and 18 nurses per 100,000 people were employed in the nation in 2003, which had a $28 US per capita health expenditure. In 2004, the country had one medical facility for every 27,000 people, and some centres cared for up to 300,000 people.

Approximately a quarter of the population lacked access to health care. Afghanistan has one of the highest per capita populations of disabled people in the world. At least one adult or child in every five Afghan households has a severe physical, sensory, intellectual, or psychosocial disability. Over 40 years of war have left over one million Afghans with amputated limbs and other mobility, visual, and hearing impairments. Numerous Afghans suffer from psychosocial disabilities (mental health conditions) such as depression, anxiety, and post-traumatic stress, which are frequently caused directly by the protracted conflict. Other Afghans have pre-existing disabilities, such as those caused by polio. Violent power transitions, extended periods of contested government, endemic poverty, and widespread lawlessness, insecurity, and hostility have undermined even the most rudimentary efforts by successive governments to conceptualise, adopt, or enforce policies addressing the needs of persons with disabilities, despite the population’s continued growth (Human Rights Watch, 2020). Disabled people face significant barriers to education, employment, and health care, all of which are guaranteed by the Afghan constitution and international human rights law. For example, many disabled Afghans lack a national identity card (Taskera), which is required to access many government services and vote in local and national elections. The distance to the district or provincial centres and lack of assistance are the main deterrents. The most common causes of disability are landmines, trauma, psychological distress, cerebral palsy, and polio. The WHO estimates that 1.5 million Afghans have partial or total blindness, caused in 80% of cases by treatable conditions (World Health Organization, 2021a). In rural Afghanistan, lack of basic health services is a leading cause of preventable disabilities.

When the Taliban took over the power in Afghanistan in 1996, since then the warfare had wreaked havoc on the country’s infrastructure and economy (BBC News, 2019). The healthcare received only a small portion of the national budget and the same system has been remained understaffed and under-equipped (Strong et al., 2005). However, the Taliban’s rule, which was fundamentalist in nature and prohibitive in approach had killed the Afghan healthcare sector (Rashid, 2010). Women were denied access to such facilities, exacerbating the inadequacy of healthcare facilities (Faiz, 1997) and female healthcare providers were prohibited from working (Dubitsky, 1999). Maternal mortality increased as outdated notions of ‘modesty’ took precedence over medical intervention (Latifi, 2019). Only one-third of Afghanistan’s districts had a maternal or child health clinic, and more than 90% of all births occurred at home. Children suffered from birth defects, malnutrition, and diseases that could have been avoided due to poor maternal health (POV BLOG, 2002). Killings in the country between 2018 and 2021 (terrorists 32,803; security forces 4,220; civilians 3,491; not specified 286).

The Basic Package of Health Services (BPHS) and the Essential Package of Hospital Services (EPHS) established the scope of the country’s health services during the Islamic Republic of Afghanistan (EPHS). The funding for both health packages came from major donors. The country has made significant progress over the past 20 years in expanding access to health services and enhancing some health indicators, despite numerous challenges in the public health sector. While life expectancy has increased since 2000, there have been notable decreases in infant and child mortality as well as maternal mortality. The gains made over the past two decades have been jeopardised by the quick withdrawal of US/NATO forces from the country following the political transition in mid-August 2021 and the temporary suspension of funding from the World Bank and other donors to the Afghan health system (World Health Organization, 2022).

The Integrated Package of Essential Health Services (IPEHS), which have increased the scope and coverage of health services and brought the nation closer to universal health coverage, was supported by the Islamic Republic of Afghanistan prior to the Taliban taking control in early 2021. The conflict and Taliban takeover later that year prevented the IPEHS from being put into action, though. Before the Taliban took control, Afghanistan’s health system was already hampered by a lack of female medical professionals, which had an impact on the delivery of life-saving services, especially for women and children. Again, girls and women are prohibited from enrolling in secondary schools, universities, and NGO jobs under the Taliban. In addition to potentially having disastrous effects on the Afghan economy, the ban on girls and women working in NGOs and on receiving an education will eventually have a significant negative direct and indirect impact on Afghans’ health. Since the Taliban took control, more than 124 000 civilians, including many medical professionals, have been evacuated from Afghanistan, further impeding the delivery of healthcare services there. Thousands of medical workers were underpaid up to a seven-month salary prior to March 2022. A survey of Afghan health care workers (HCWs) revealed that 68% of them purchased personal protective equipment with their own money. The health of Afghans is also still negatively impacted by poverty and food insecurity, with an estimated 20 million people in need of food assistance (Nemat et al., 2021).

Since the Taliban took control, female education and employment in NGOs have also been prohibited. In order to pursue higher education and job opportunities, many female nurses, for example, left the country due to political unrest, a lack of funding for obtaining a bachelor’s or master’s degree, and a lack of nursing programmes available (International Council of Nurses, 2021). The country’s health system was weak and unable to respond with emergency measures after the most recent natural disasters, which included heavy rain, landslides, and earthquakes on 21 June 2022, in the southeast provinces of Paktika and Khost, were so deadly. In 17 districts of the provinces of Paktika and Khost, at least 1036 people were killed, 6083 were injured, and 4500 homes were destroyed, affecting 361 634 people (OCHA Services, 2022). Due to Afghanistan’s dependence on foreign aid for 80% of its budget, more than 20 million people there needed humanitarian aid to survive (Cordesman, 2022).

As concerns about the rapidly deteriorating medical and humanitarian situation in Afghanistan under the Taliban have increased, the UN and humanitarian partners offered interim support to maintain some aspects of the country’s health-care delivery, including through the multi-donor Afghanistan Reconstruction Trust Fund with the Health Emergency Response project to maintain the provision of BPHS and EPHS until the end of June 2024. As the conflict in Ukraine commanded the attention of the international community, the UN opened a pledging conference to protect the livelihoods of Afghanistan. This pledging event gathered US$2.4 billion was granted (United Nations, 2022). However, only 13% of the goals achieved in the 2022 Humanitarian Response Plan were funded by fundraising, underscoring the requirement for urgent financial support to continue at least through 2022 (Narain et al., 2022). As a result, the health care systems in Afghanistan have collapsed due to political unrest, severe natural disasters, and a lack of international assistance. Unless the current political issues, ineffective disaster prevention, and lack of international support are acknowledged and effectively resolved, the previous improvements in health outcomes are likely to be lost, and residents may continue to suffer from health care deprivation. Because of this, long-term sustainability of the nation’s health system depends on increased domestic resource allocation to health services. In the near future, it will be necessary to increase domestic health resources through co-financing mechanisms and other means. In addition, ongoing assistance from the international community is essential to maintaining the delivery of health services and reducing the effects of Afghanistan’s severe humanitarian crisis. The nations that withdrew from Afghanistan in 2021 have a moral obligation to consider various tactics to continue assisting and facilitating constructive changes that might result in a better future for Afghanistan. The international community must work closely with Afghans and support initiatives that aim to protect human rights, particularly for women and girls, and to ensure that everyone in Afghanistan has equal access to health care, education, and employment opportunities as well as enough food and shelter.

Conclusion

Social Determinants of Health, conflict/war and public health have been interwoven strongly with one and another. Afghanistan has been crippled given the couple of decades of civil war and thereby impacting its economy. The analysis of the paper found that the conflict/civil war used to severely impact the GDP/economy. Consequently, in context of Afghanistan, the protracted conflict had resulted into poor economic health of the country along with poverty, unemployment displacement, deprivation of basic necessities etc. laming the Social Determinants of Health (SDHs). Therefore, Afghanistan has been unable to provide healthcare services to its citizens. The same was further aggravated by the unavailability of healthcare personnel, infrastructure destruction, and disruptions of multilateral lifelines supply chains etc. A well-established notion in the health studies of Afghanistan is that social determinants have an impact on country’s health-care system and infrastructure.

In this situation, the role of GHD became one of the important factors for taking care of the healthcare needs. It is also found that GHD is used to facilitate for the provisions of medical healthcare during times of health crisis particularly during the ongoing war/conflict. The World Health Organization has played a pivotal role in the improvement and expansion of healthcare facilities in Afghanistan. As part of a WHO-MoPH Joint Program, the WHO has been working with Afghanistan’s government to implement the country’s National Health Policy 2015–20 and the 2018–2019 Country Plan. As part of the ‘Sehatmandi Project’, which is overseen by the MoPH, the World Bank Group, the Afghanistan Reconstruction Trust Fund (ARTF), WHO, the United Nations, the European Union, the United States Agency for International Development, and Canada have joined forces. In the same way, the MoPH has also received assistance from UNICEF in developing and implementing community-based newborn care at the national level. Apart for that, many countries have been individually involved in the reconstruction aid to Afghanistan. Thus, A range of diplomatic considerations are required while delivering global health programmes in conflict and post-conflict settings which would ensure health gains and SDHs to tackle societal challenges to local cultural, religious and social norms. They have the potential to produce diplomatic outcomes that are difficult to quantify. In conclusion, global health diplomacy is critical in today’s world to bridge the concepts of health and peace, while also building healthy relations between nations to help war-torn countries like Afghanistan. While Afghanistan is in a vulnerable transition period, other countries like Rwanda and Vietnam have shown that a committed group of stakeholders can achieve a lot despite the odds. So, future research can build on this foundation by examining the relative importance of the various health factors that influence social determinants of health in greater depth.

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No potential conflict of interest was reported by the author(s).

Additional information

Notes on contributors

Bawa Singh

Kulwinder Singh (PhD) is working at the University Business School as Assistant Professor since June, 2014. He has completed his Ph.D. in Economics on the topic entitled ‘Economic Reforms, WTO and India’s Exports: An Analysis’ in the area of International Trade. He has published 3 academic books, 20 scholarly research papers/chapters in various national and international journals/books. Email Id: [email protected]

Sandeep Singh

Kulwinder Singh (PhD) is working at the University Business School as Assistant Professor since June, 2014. He has completed his Ph.D. in Economics on the topic entitled ‘Economic Reforms, WTO and India’s Exports: An Analysis’ in the area of International Trade. He has published 3 academic books, 20 scholarly research papers/chapters in various national and international journals/books. Email Id: [email protected]

Jaspal Kaur

Jaspal Kaur, Assistant Professor in the Department of Sociology at Lovely Professional University, Jalandhar, Punjab, India. Email Id: [email protected]

Kulwinder Singh

Kulwinder Singh (PhD) is working at the University Business School as Assistant Professor since June, 2014. He has completed his Ph.D. in Economics on the topic entitled ‘Economic Reforms, WTO and India’s Exports: An Analysis’ in the area of International Trade. He has published 3 academic books, 20 scholarly research papers/chapters in various national and international journals/books. Email Id: [email protected]

Abdul Wasi Popalzay

Abdul Wasi Popaljay is a PhD Scholar, in the Department of South and Central Asian Studies, Central University of Punjab, Bathinda, India. Email Id: [email protected]