Political Instability, Brain Drain, Restrictions on Female Workers, and Shrinking of International Aid Will Undermine Immunization Campaigns

By: Ghulam Dastagir Nazari

The immunization program in Afghanistan was under the support of UNICEF and WHO before the year 2003, and it was limited only to cities and a restricted number of districts. After 2003 immunization services were included in the Basic package of health services BPHS and the Essential package of health services EPHS funded by the world bank, USAID, EU, the Government of Canada, and other donors and managed by the ministry of public health of Afghanistan following the years the number of health facility provided immunization services increases from the 423 in 2003 to 2521 in 2021. The number of vaccines increased from 6 antigens in 2003 to 13 antigens in 2021, preventing children from getting infected against nine vaccine-preventable diseases.

From 2001 to 2021, partner countries conducted multiple capacity-building programs at different levels to build the human capital needed to manage the program and reduce the human resources dependency on international partners. These capacity-building programs included the three months initial courses for vaccinators, mid-level manager training for the provincial level manager to educate them on the planning and implementation of the program, field epidemiology training program FETP for national and provincial managers, and several international vaccine programs for national managers. All those capacity-building programs reduced the human resource dependency on international partners, where the EPI program could investigate, plan and implement all the necessary interventions for the program.

Following the collapse of the government in August 2021, a considerable number of Human resources left the country from different levels of the program, which increased the workload on other trained staff in the early days of the collapse. When the Taliban took over the ministry and appointed their acting minister of Public Health, the firing process of those trained staff started, leading to a complete disaster. As per the information from the Human resource department of the ministry of public health, over 90% of the staff at the managerial level has been replaced by new untrained staff, which increases the human recourse dependency on international partners and as the Taliban de-facto authorities announced new restrictions on work of female employ this dependency is reached to the highest point in the past two decades. 

Break in the contract of NGOs

Once the government collapsed, the world bank stopped all financial support to the public health ministry, acting as the contractor of health packages to the NGOs. The seizure of support from the World Bank led to a dispute between NGOs and the ministry. The conflict between the Ministry and NGOs affected the service delivery level, with health facilities going out of all sorts of medical supplies for months. After three months of a gap, the world bank started mobilizing funds to the UN agencies (WHO, UNICEF) and through them to the non-government organizations (NGOs) that used to implement the health services, now in the upsent of trained staff to monitor and make sure the quality of services delivered by the NGOs the quality of services compromised and lead to an increasing number of vaccine-preventable diseases outbreaks in the year 2021 and 2022.

International partners started recruiting international staff to overcome the human resource gap, which helped control the situation.

Displaced population and its effect on disease spread

In the past few years, internal displacement of the population in Afghanistan was due to drought, multiple players including the ministry of public health were planning to provide the required services to the displaced population, but once the battlefield moved from the remote districts to the cities and more geographical area fall in the hand of so-called anti-government elements a mass displacement started towards the regional cities and capital Kabul, By the end of 2021, an estimated total of 4.3 million afghans were living in internal displacement. Among the stock of internally displaced persons (IDPs) globally, Afghanistan hosted the highest number of IDPs due to disasters and the fourth highest number due to conflict and violence. Those displacements with no proper sanitation and shelter led to multiple disease outbreaks where the ministry of public health, with all international partners, could not control them for months. As an example, the number of measles cases and deaths increased by 18% and 40%, respectively, in the last five months of 2021 compared to 2020.

Current diseases outbreak in the country

Afghanistan is dealing with the multiple diseases outbreak at the moment, and factors like the decline in international funding, brain drain, restriction on female workers at the managerial level in non-governmental organizations, including UN agencies, and lack of ownership of the ministry of public health are restricting the interventions to control these outbreaks. As a result, the number of infected cases and deaths is going in a levitation manner. Currently, acute watery diarrhea cases are reached 256,795 cases from May 2022 to February 2023, with new cases of 2,339 in the last week and 92 deaths in the mentioned period, the number of measles cases despite the national campaign in 2022 has reached 81,277 cases from January 2022 to February 2023 with the new instances of 822 in the last week and 404 deaths in the mentioned period, number of dengue cases from June 2022 to February 2023 has reached to 1,311 with seven new cases in the last week.