“When there is no competition, then you have [to] employ whoever is available to do the job,” he said.
Ongoing security concerns affect access to care
A 2016 study shows that large inequalities in health care access continue to exist across the country. The majority of the population lives in rural areas where there is lower coverage of health services and fewer health workers; in urban areas, there are 36 health workers per 10,000 people, compared to less than 17 health workers per the same population in rural areas.
According to Dr. Mohammad Fareed Asmand, executive director of NGO Afghan Health and Development Services, or AHDS, much of the inequality around access and quality of care comes down to the lack of trained staff, especially in the most remote and insecure areas. The further away from the capital city, Kabul, the lower the quality of health care and the less applicants for health care posts, he said.
Security is a monumental challenge, with health facilities in Afghanistan frequently under attack. According to the World Health Organization, there were 55 reported attacks on health care facilities in the first quarter of 2019, killing at least nine workers and patients and causing the closure of at least 87 medical facilities due to instability.
This affects recruitment, and often health staff want to avoid being posted in conflict zones. “Nobody wants to go there [because it’s] dangerous for their lives,” Fareed said.
However, according to van Hal, in many of the country’s provinces, health care is provided by NGOs because they are not part of the conflict and will therefore be more easily accepted. But it is particularly difficult to deliver health services in the parts of the country where the opposition is in control.
If the health care provision is associated with the government, the opposition may say “we don’t want you”, or they may even attack you, he said, adding that Cordaid has to make sure that the opposition understands they are not politically motivated.
According to Albert van Hal, the international community should be patient and continue to support Afghanistan's efforts to build a strong health system.