40 years of violent conflict have caused waves of displacement and mobility within Afghanitan and across its borders. Annually, an average of 500,000 undocumented migrants return from Iran and Pakistan; 250,000 persons are affected by natural disasters and 200-400,000 are displaced by conflict. Despite the advent of peace negotiations between the Taliban and the Afghan State in September 2020, new levels of violence have been triggered in 24 of 34 provinces with a series of high profile suicide attacks against military and civilian targets including hospitals in Kabul and other urban centers. Attacks on health care including static facilities and health workers are an increasing feature of daily life in Afghanistan.
In 2020, COVID-19 saw its first casualties in February. Over 45,000 persons have since been test confirmed positive with nearly 1,800 deaths as of late November 2020, however the true infection rate is believed to be many times higher as indicated by several national wide assessments with prevalency rates as high as 90% in some provinces with IOM’s own staff were severely impacted by COVID-19 infections in 2020. Limited availability of testing materials, reluctance on the part of community members to be tested and socio-cultural norms have combined to deter health seeking behavior. Public confidence in the health care system is at an all time low where at least 9% of all COVID-19 infections are frontline health care workers. Visitations to health facilities have declined by 25% in 2020. With more and more Afghans out of work, the cost of paying for medicines and other advanced forms of care within the public system and the higher cost of private care will be increasingly prohibitive for most.
COVID-19 will continue to have profound and long term impacts on both the Afghan economy which is set to contract by 7.4% in 2020 and the health outcomes of the Afghan population for many years to come. Using polio as an example, and despite the success of recent vaccination trials, Low and Middle Income Countries (LMICs) like Afghanistan may not have early access to vaccines where supply chain and production issues, insecurity and violence may mean that the successful roll out of comprehensive vaccine coverage could be years in the making.
In addition, the results of the 2021-2024 Afghanistan Conference held in November 2020 in Geneva witnessed a 20% overall cut in pledges from international donors. Only 3.3 Billion USD in pledges for 2021 are confirmed with the remaining 9 billion USD dependent on progress in peace talks and other performance based indicators. This does not bode well for Afghanistan’s 300m USD per year NGO-led Integrated Package of Health Services where funding is likely to be cut.
Moreover, given the rates of return and displacement, mobile populations typically fall outside of the catchment areas of static health facilities and mobile health remains limited in scope.
As of early December 2020, nearly 800,000 undocumented migrants returned to Afghanistan with over 99% returning from Iran through the Herat (Islam Qala) and Nimroz (Milak) border crossings.1 Given the scale and magnitude of cross border returns in addition to the full scale reopening of the borders, the epidemiological profiles related to COVID-19 transmission, and the complex health needs of returnees, there is a need to improve the coordination and delivery of existing health services at border areas and areas of return.
According to the IOM’s Displacement Tracking Matrix (DTM), Community Needs Assessment January to June 2020, access to health and education was marked by similar challenges. The top three reported ailments were fever, respiratory infections and watery diarrhoea, symptoms in line with those of COVID-19.
These findings indicate a need for increased Infection Prevention and Control (IPC) measures, including increased COVID-19 risk information provision at the community level.
On average access to healthcare is 23 kilometres away from settlements, only 23% of survey participants stated they had access to healthcare facilities within their settlement.
Access to adequate care was further reduced by overall low service quality, lack of medicines and staffing. The absence of female staff was also among the top four reasons not to use the nearest healthcare facility.2 While limited access to essential health services affects the entire population, IDPs and returnees are acutely disenfranchised. Across the country, health development indicators remain stagnant and, in some cases, immunization coverage has declined. According to the recent Whole of Afghanistan assessment, a quarter of the population (9.4 million) will require multi-sectoral assistance, symptomatic of the convergence of physical and psychological trauma, displacement, lack of health services, malnutrition and general poverty compounded by the diminishing economy and loss of livelihoods.