Health care is free under the Constitution. Yet the government appears to be building up a case for the implementation of a user fee.
A two-year-old study conducted by the Ministry of Public Health (MoPH) had said Afghans spend roughly 55 USD each on health care.
A two-year-old study conducted by the Ministry of Public Health (MoPH) had said Afghans spend roughly 55 USD each on health care. Of this a mere 6 percent is borne by the government although Afghans are guaranteed free health care under Article 52 of the Constitution.
The study also revealed 73 percent comes out of people’s pockets including costs of medicines and shirini (literally sugar) which is money that has to be paid under the table to get access to doctors and hospitals. The rest, 21 percent, is met by assistance from the international community.
Officials in the MoPH and Members of Parliament (MPs) argue that free health care is beyond the ability of the government and the Constitution should be amended. Deputy Minister of Health in Policy and Planning Dr Ahmad Jan Nayeem says, “Health is not free anywhere. Either the patient or the government or donor has to pay. When the Ministry of Finance (MoF) does not have the money to pay the salaries of government officials we say there should be free and quality health services! This is a big demand. I don’t think poor and developing countries can have the ability to do so.”
Dr Naqibullah Fayeq who heads the parliamentary commission on health, sport, youth and labour, says, “Even if we were to transfer half of the government’s total budget to health care it would not be enough.”
Quality argument
Policymakers are pushing for implementation of a fee for some health facilities. The money raised will go a long way to enable the government to deliver better health services through public hospitals and health centres, Fayeq believes. But he clarifies that basic health services like vaccinations, maternity services and emergency aid would not be charged in remote areas.
Minister of Health Dr Suraya Dalil told Killid, “The government is obliged to provide free health care but it is impossible.” She explains that “some services” must be free like emergency services in case of bomb attacks or natural disasters, maternal and child health care, and epidemics. But she thinks serious illnesses like cancer or heart disease cannot be free except for poor people.
Minister Dalil says her ministry is working together with the Ministry of Justice and the Council of Ministers on amendments to the law which when passed will be a big step for the health sector. She claims the new law will clearly define all free health services, which is referred to only in general terms in Article 52. The Constitution makes it the government’s responsibility to provide free means of prevention and treatment to all citizens. “We will define the health facilities and health equipment that will be free. This includes beds, machines, ambulances and facilities like buildings,” she says.
Deputy Minister Nayeem thinks health care should not be free since “no free thing is of good quality”.
Access to health
The MoPH claims 60 percent of people have access to health services today compared to 9 percent 12 years ago. Minister Dalil thinks should security and road infrastructure improve, Afghanistan can have near universal health care by 2020. “With better roads we don’t need to have a health facility in every village,” she says.
Save the Children, the international NGO, thinks the situation has improved considerably. For years Afghanistan was considered the worst place for women.
Dr Mohammad Akbar Sabwoon, health and nutrition advisor to Save the Children, says in 2014 Afghanistan was 146 out of 187 countries, and the worst country for mothers was Somalia. Afghanistan has improved in all five indicators including maternal mortality and female education.
MoPH figures from a 2010 study show that while 1,600 out of 100,000 women were dying in childbirth in 2002, it had decreased to 327. Under 5 deaths had also dropped from 327 out of 1,000 children to 97.
Minister Dalil says, “In the past one mother died in child birth every 27 minutes. Now it is within two hours. We have also made achievements in infant mortality: one out of four new borns died five years ago. Now one out of 10 under five year olds die.”
The ministry has been immunising children against childhood diseases that kill like Diphtheria, polio, tetanus and measles. “One of our great works is the immunisation programme for women and children,” Minister Dalil told Killid very proudly.
Save the Children’s Sabawoon praises the achievements made in maternal and under five mortality but points out progress in new born deaths was slow. In his opinion the policies are good but implementation is weak. “The policy that exists in sector of health of children and adolescents is good but it has not been implemented due to lack of capacity, and financial means by MoPH,” he says.
Human resources
The acute shortage of health professionals particularly female doctors and nurses has not been solved. Save the Children estimates there are only 7 health practitioners for 10,000 people. This includes a midwife and doctor. The World Health Organisation (WHO) considers 23 health practitioners as ideal.
Dr Sabawoon thinks the high birthrate can be blamed on the fact that 60 percent of deliveries are not assisted by midwives. The remoteness of villages and disturbed security situation are additional problems.
Training more female medical staff is of utmost importance, says Sabawoon. MoPH estimates there are 4,000 midwives in the country. There were 490 in 2002. “The work to increase human resources is going on. The problem cannot be solved at once,” says Deputy Minister Nayeem defensively.
There are five times the number of public health centres including district hospitals and primary health centres. More than 12,000 pharmacies are registered with the MoPH. The average life expectancy has gone up from 46 years to 62.
The Afghanistan Investment Support Agency (AISA) estimates 23 million USD has been invested in health infrastructure including pathology facilities and hospital buildings. There are some 20 foreign healthcare companies and 300 Afghan companies invested in the country, according to AISA deputy director, Mohammad Ibrahim Shams.
But much more needs to be done to ensure uniform health care services. Deputy Minister Nayeem counts shortage of funds as one of the main hindrances to the expansion of public health care. “We propose 30 projects to the MoF but they approve just two or three,” he says. Nayeem wants the international community to increase health budgets.
Head of the parliamentary health commission Fayeq says after security it is the health sector that gets the largest share of foreign aid. “Until 2018 the international committee is committed to providing us assistance. Thereafter we will adjust health services to the situation,” he says.
MoF spokesperson Abdul Qader Jailni told Killid the ministry allocates money according to its resources. “When the revenue goes up the financial situation will improve,” he adds sagely.
MoF figures for the MoPH in 1393 was 328 million USD compared to 189 million USD for the previous year. The international community, which promised a total of 2.6 billion USD has given the amount. Jailni says the money has been spent. “This figure includes all aid that has been spent in the government’s optional and non-optional developmental budget.”
In an interview with Killid WHO representative in Afghanistan Dr Rik Peeperkorn urges all stakeholders in the country to invest more in health care.
“When we see that every Afghan spends 55 dollars annually on health, there is need that all (the Afghan government, people, and international community) should take part in improving the situation but the main responsibility is on the government to invest in cooperation with the WHO and donors. As the share of donors and the government increases the health burden on the poor would decrease,” he observes.
