Summary

The sharp reduction in financial and technical development support for Afghanistan’s public health system since the Taliban takeover in August 2021 has severely harmed the country’s healthcare system. The lack of sufficient healthcare services has undermined the right to health for millions of Afghans and has left the population vulnerable to disease and other consequences of inadequate medical care. Women and girls have been disproportionately affected by the healthcare crisis, particularly because of Taliban abuses. The Taliban’s restrictions on women’s freedom of movement and employment with humanitarian and other organizations have gravely impeded women and girls’ access to health services, while bans on education for women and girls have blocked almost all training of future female healthcare workers in the country.

The collapse of the Afghan economy and the loss of hundreds of thousands of jobs after the Taliban takeover drove many Afghans into extreme poverty, leaving them unable to pay medical expenses, worsening their social determinants of health, and threatening rights essential for maintaining an adequate standard of living, including the right to food. The result has been life-threatening for many Afghans, including millions of children suffering malnutrition. Almost two-thirds of the Afghan population needed humanitarian aid by the end of 2023. Cuts to international humanitarian assistance in 2023, with more anticipated, and a longstanding drought have further threatened the availability and accessibility of adequate food and exacerbated the crisis.

Over the previous two decades, the Afghan government had depended on international development support from donors to fund essential services like primary health care, even as Afghans paid the majority of healthcare costs from their own pockets. The previous government’s own contribution to the public primary care system was negligible, leaving it vulnerable to collapse once aid was withdrawn. Donor development aid for Afghanistan’s public health system was approximately six times the government’s own expenditure on health, with rising insecurity and declining donor support after 2012 already causing staffing and supply shortages. After the Taliban takeover, the World Bank and other donor countries and institutions cut all development funding, including for health, although humanitarian aid temporarily increased in 2021-2022, only to face cuts in 2023. The sharp drop in development support sent a shock through the economy and the public health system; compounding the crisis, many Afghan healthcare professionals left the country or quit their jobs.

Humanitarian aid organizations have tried to make up for the loss of donor-provided public health funds, particularly in hospital support, however they cannot replace what had been provided for the public health system. With the decrease in funding for humanitarian assistance after 2022, aid organizations have shifted their focus toward immediate relief efforts only. Temporary support to public hospitals immediately after August 2021 prevented a total collapse, but aid organizations have also closed clinics due to a lack of funds, and local aid groups that cannot import their own supplies have reported shortages of medicines and equipment. Humanitarian assistance and exemptions to sanctions prevented a worse catastrophe in the first two years after the Taliban takeover; however, shrinking humanitarian aid now imperils the entire Afghan population.

The Taliban’s bans on many forms of women’s employment have added to the crisis by violating their rights to an adequate standard of living and depriving them and their families of needed income. Women have been banned from most civil service jobs, from employment with nongovernmental organizations (NGOs) and the United Nations except for specific positions in health care and education, and from some private sector jobs.

Because only women can interview women in their homes about their needs and those of their children, Taliban restrictions have obstructed efforts by humanitarian aid organizations to carry out assessments in communities to identify those in need of aid and the kinds of assistance required, and to deliver assistance equitably. Taliban regulations, in particular compelling female healthcare workers to be accompanied by a mahram (male relative guardian) while traveling or in some instances during work hours, and the imposition of strict hijab rules have created onerous obstacles for women delivering and receiving health care.

The Taliban, by imposing bans on secondary and university education for girls and women, have denied them their rights to education and health and effectively guaranteed that shortages of female healthcare workers will continue for the foreseeable future. The Taliban have also failed to allocate adequate resources to public health; like the previous government, they have instead relied on donors to fill what has become a widening gap in Afghans’ access to affordable health care.

The collapse of the former government and loss of development and security assistance across all sectors also led to widespread unemployment, as many jobs in the civil service and with NGOs disappeared overnight. While Afghans living in poverty have always faced difficulties accessing health care because of costs, a rising number of Afghans now struggle to pay for food and are often unable to cover the price of medicines and transportation to reach health services.

Among those most affected by Afghanistan’s economic crisis are people with disabilities. Due to decades of conflict and poor maternal health, Afghanistan has one of the largest populations in the world of people with disabilities. Because of aid shortfalls, some NGOs that had provided services for people with disabilities no longer do. Some Afghans who had served in the previous government’s armed forces and who acquired disabilities from the war have lost access to the financial benefits they previously received. The Taliban’s policies banning women from traveling and in some cases working without a mahram have also had a particularly detrimental impact on women with disabilities and on women caring for others with disabilities, including on their ability to access services and benefits.

The serious rights violations described in this report derive both from the collapse of Afghanistan’s economy and public health system and the impact of the Taliban’s abusive policies and practices. Actions taken by the United States and other governments in August 2021 to cut off Afghanistan’s Central Bank from the international banking system, ongoing difficulties with banking despite clarification of the limited scope of sanctions, and the sudden loss of foreign spending delivered a critical shock to the economy from which it is still suffering. At the same time, the Taliban have allocated little to public health and have erected oppressive obstacles to training and deploying healthcare workers, especially women. The Taliban have been responsible for violating the rights of women and girls to health care, education, and livelihoods. These abuses have exacerbated Afghanistan’s economic crisis, thus prolonging the threat to Afghans’ rights to livelihoods and an adequate standard of living long into the future.

Taliban’s International Legal Obligations

As the authorities maintaining effective control in Afghanistan, the Taliban have international legal obligations under international human rights law. Under international human rights law, every person has the right to the highest attainable standard of physical and mental health, the right to nondiscrimination, the right to an adequate standard of living including the right to food, and the right to freedom of movement, among other fundamental rights.

These rights are guaranteed by core international treaties to which Afghanistan is a party, including the International Covenant on Economic, Social and Cultural Rights, the International Covenant on Civil and Political Rights, the Convention on the Elimination of All Forms of Discrimination against Women, and Convention on the Rights of Persons with Disabilities.

The right to enjoy the highest attainable standard of health is guaranteed by several treaties. This right not only includes the prevention, treatment and control of diseases, but “the creation of conditions which would assure to all medical service and medical attention in the event of sickness.”

General Comment 14 of the UN Committee on Economic, Social and Cultural Rights states that the right to health is “an inclusive right extending not only to timely and appropriate health care but also to the underlying determinants of health such as … access to health related education and information, including on sexual and reproductive health.”

On nondiscrimination and equal treatment, the Committee said that:

the Covenant proscribes any discrimination in access to health care and underlying determinants of health, as well as to means and entitlements for their procurement, on the grounds of race, color, sex, language, religion, political or other opinion, national or social origin, property, birth, physical or mental disability, health status (including HIV/AIDS), sexual orientation and civil, political, social or other status, which has the intention or effect of nullifying or impairing the equal enjoyment or exercise of the right to health.

The Committee noted that:

many measures, such as most strategies and programs designed to eliminate health-related discrimination can be pursued with minimum resource implications through the adoption, modification or abrogation of legislation or the dissemination of information. … [E]ven in times of severe resource constraints, the vulnerable members of society must be protected by the adoption of relatively low cost targeted programs.

With respect to the right to health, equality of access to health care and health services has to be emphasized. Governments have a special obligation to prevent any discrimination in the provisions of health care and health services, especially with respect of the core obligations of the right to health.

Access to health cannot be limited on the basis of discrimination. All people must be able to access health care, regardless of gender, ethnicity, sexual identity, poverty or other status.

The Convention on the Rights of Persons with Disabilities makes clear that governments “shall take all appropriate measures to ensure access for persons with disabilities to health services that are gender-sensitive, including health-related rehabilitation.”

 

Recommendations

Human Rights Watch has reported on serious human rights abuses and violations of international humanitarian law by the Taliban before and since their takeover of Afghanistan in August 2021. We have concluded that the Taliban’s violations of the rights of women and girls amount to the crime against humanity of persecution based on gender. In addition to Taliban bans on secondary and university education, many forms of employment, and restrictions on freedom of movement, the barriers women face to accessing health services compound Afghanistan’s healthcare crisis by reducing the availability and accessibility of healthcare goods and services for women and girls.

The Taliban’s miniscule spending on health care has exacerbated the harmful impact of Afghanistan’s aid dependency. For many years Afghanistan has been among the lowest-ranked countries in terms of the percentage of Gross Domestic Product (GDP) it spends on public health, falling far below what the World Health Organization (WHO) has found necessary to ensure universal health coverage.

While donor support for Afghanistan, including for the healthcare sector, was shrinking even before the 2021 takeover, the Taliban’s disregard of widespread international pressure to reverse their repressive policies and end their violations of women and girls’ rights may deter some donors from considering development funding for programs in Afghanistan. The US and other governments established the Swiss-based Fund for the Afghan People to preserve and protect US$3.5 billion in frozen assets that were transferred to it, and to utilize some of those assets in support of Afghanistan’s macroeconomic stability. However, the Fund has yet to disburse any funds to Afghanistan’s central bank. Efforts to provide technical assistance to Afghanistan’s central bank (Da Afghanistan Bank) have not been successful, as the bank has yet to pass critical audits and provide other assurances of its autonomy from the Taliban. Despite the political impasse, many donors have increasingly recognized that while aid has mitigated the worst effects of the humanitarian crisis in the short term, it is insufficient to stabilize Afghanistan’s economy, support livelihoods, and provide adequate public health care.

To the Taliban:

• Remove all restrictions that impede or delay people’s access to health care and humanitarian aid, including for women and girls, and continue to allow and facilitate timely and dignified access to health care, without conditionality.
• Repeal all decrees and policies violating the rights of women and girls, including those listed below. Immediately end bans on women’s employment in all sectors and lift all restrictions on women’s freedom of movement, including mahram requirements.
• Consistent with the WHO benchmark of 5 percent of GDP, progressively increase funding for the public health system, especially in the areas of sexual and reproductive health care, child nutrition, and disease prevention. Expand and improve primary healthcare facilities, especially in underserved rural areas.
• Immediately end bans on secondary and university education for women and girls. Ensure that schools teach a curriculum designed to equip both girls and boys for careers that include working as doctors, nurses, and other health care professionals. Allow female graduates to take their exit exams so as to be able to work in the health sector. Expand opportunities for girls and women to prepare for careers in health care.
• Allow female health workers to travel in mobile clinics to reach underserved communities. Improve outreach and access to health care, including psychosocial support.
• Ensure that people with disabilities, including those who served in the armed forces of the previous government, have access to targeted community outreach and social services, and financial assistance on an equal basis with others.

To Donor Countries:

• Seek opportunities to coordinate and work in concert to press Taliban leaders to remove all restrictions that impede or delay people’s access to health care and humanitarian aid and revoke decrees and policies violating the rights of women and girls, especially those affecting access to health care.
• Increase and sustain funding for the Afghan healthcare system to meet immediate needs and work toward supporting long-term measures for sustainable healthcare delivery. This should include funding improvements to service delivery, such as trained medical and professional personnel and healthcare infrastructure, especially facilities that provide primary services, those in rural districts, and those aimed at providing services to women, children, and people with disabilities on an equal basis with others, as well as targeted services for those with disabilities.
• Address Afghanistan’s economic crisis by supporting measures to normalize payments and other transactions through Afghanistan’s banking system. The United States and other governments should continue to apply measures such as sanctions on individuals designed to pressure Taliban leaders to end their abuses. But the US and other governments should redouble efforts to reach agreements with authorities to allow monitored international transactions involving the Afghan Fund and central bank meant to facilitate banking liquidity and legitimate financial transactions, including those for humanitarian aid and trade.
• Help restore public services in the areas of water management, irrigation, and agriculture that are essential to restart the economy, address income-related poverty, and improve non-medical health indicators vital to the social determinants of health, including sanitation, climate adaptation, and food availability.
• Increase support for training and education programs for girls and women in health-related fields through scholarships, alternative learning programs, and other available means.
• Support and expand services for people with disabilities in Afghanistan, including through psychosocial counseling programs.
• Support expanded humanitarian cargo flights to bring in needed medicines.

Methodology

Human Rights Watch carried out research for this report between February 2023 and January 2024. The report is based on a total of 46 remote interviews, using secure communications, with NGO officials, healthcare workers, and adults seeking health care in 16 provinces of Afghanistan, including the major cities of Herat, Kabul, Kandahar, and Mazar-e Sharif, and rural areas of Sar-e Pul, Bamiyan, Daikundi, Ghor, Helmand, Kapisa, Kunduz, Nangarhar, Paktia, Parwan, Takhar, and Uruzgan. Fifteen of the interviews, 12 women and 3 men, were with Afghans who had sought health care. Of the Afghan healthcare officials interviewed, 10 were women and 8 were men. We also reviewed reports on Afghanistan’s healthcare system by government sources and international humanitarian organizations.

Interviews were conducted in Dari and Pashto with the informed consent of the interviewee. The names of the interviewees and specific location information have been withheld to protect their identities.

All interviewees were informed of the purpose of the interview, the ways in which the information would be used, and offered anonymity in our reporting. In some cases, we have used pseudonyms, which appear in quotation marks, to anonymize individuals for their security. None of the interviewees received financial or other incentives for speaking with us.

On January 9, 2023, Human Rights Watch sent a summary of our findings to the Taliban authorities in Kabul. As of publication we had not received a response. Our letter appears in appendix 1.

 

I. Afghanistan’s Aid Dependency

The Afghan reconstruction effort that followed the United States-led invasion in 2001 pumped billions of dollars into the new Afghan state. For the next two decades, spending by foreign armies, funding of the security services, and international development aid supported a bloated service-led economy and paid for most public services.[1] While Afghanistan had been dependent on foreign aid to pay for its security and development since at least the mid-20^th century, and on other forms of external funding going back to its beginnings as a nation-state, the volume of aid after 2001 dwarfed all previous assistance.[2] International military spending in-country dropped sharply after the end of the “surge” in 2011, with most NATO forces withdrawing by the end of 2014. However, development and security assistance still financed more than 75 percent of total public expenditure through the first half of 2021, including around 50 percent of the national budget.[3]

Prior to 2001, Afghanistan had some of the worst health indicators in the world. The minimal facilities that then existed, some of which were ostensibly provided by the Taliban authorities that ruled most of Afghanistan between 1996 and 2001, were staffed and supported financially by nongovernmental organizations (NGOs).[4] Between 2002 and early 2021, the World Bank, the US Agency for International Development (USAID), and the European Union funded much of Afghanistan’s primary public healthcare system (through the Basic Package of Healthcare Services), paying for international and national NGOs to implement the Ministry of Public Health’s primary health programs.[5] This did not include private healthcare providers. Thus, while external donors funded a weak network of nonprofit providers that offered economically accessible health care, the Afghan government itself spent very little on the healthcare system.[6] In this highly regressive model of healthcare financing, Afghans paying out-of-pocket represented the largest percentage of healthcare costs, including for transportation to access treatment not available in rural areas.

By 2009, NGOs were delivering basic health services in up to 30 provinces, funded by USAID, the World Bank, and the European Commission.[7] While increased aid led to a four-fold increase in the number of primary health facilities between 2001 and 2014, gains were not even across provinces. Rural areas where the conflict was most intense continued to lack qualified health workers, and female staff in particular.[8] Due to corruption, a number of clinics constructed with donor money in some districts were empty: ghost clinics with no staff. In rural areas, where conflict was prolonged and intense, such as Helmand, there were few clinics.[9]

Although the donor-funded public health system was meant to provide at least primary care for free, most healthcare costs were paid by individuals, and the private health sector was larger than the public system. Hence, even before the Afghan economy collapsed in 2021, poverty was a consistent and growing obstacle to accessing health care, due largely to out-of-pocket costs for fees and medicines.[10]

In 2019, healthcare costs in Afghanistan amounted to $2.8 billion, 20 percent of which was provided by donors, and only about 3 percent by the government.[11] Out-of-pocket spending by Afghans on health accounted for nearly 77 percent of all healthcare spending.[12] The sudden end to most foreign spending sent the economy into a freefall. With the breakdown of the economy, most Afghans could no longer afford the out-of-pocket health costs they previously bore. Afghanistan’s economic crisis has driven more people into poverty and precarity, making the healthcare system based on out-of-pocket expenditures even more regressive, further infringing on the right to health.

The overnight disappearance of millions of jobs and a multi-year drought contributed to the crisis, leaving millions of Afghans unable to buy enough food to feed their families or pay out-of-pocket costs for health care.[13] A 54-year-old man living in Herat said, “I have always been under treatment for my kidney infection. Since the Taliban took over, the prices of my medications have nearly doubled. This is too much for anyone who doesn’t have a job.”[14]

Humanitarian officials have said that the needs of the Afghan population after 2021 have grown beyond what humanitarian organizations could manage.[15] At a panel in September 2023, Mercy Corps country director for Afghanistan Dayne Curry said:

The humanitarian response in Afghanistan simply cannot keep pace with the country’s worsening conditions. …These needs skyrocketed with the collapse of the former government and the subsequent suspension of international aid. Two years later, shocks from recurrent drought and seasonal flooding continue to threaten Afghanistan’s critical agriculture sector and limit access to clean water. Additionally, policies restricting individual freedoms, particularly those of women and girls, impede the humanitarian response, and Afghanistan’s authorities lack the capacity to provide services to their people. Compounding these challenges is the reality of the international community’s declining commitment to Afghanistan.[16] 

At the same panel, Becky Roby of the Norwegian Refugee Council said:

While humanitarian actors provide life-saving assistance, these interventions cannot by themselves improve the situation for affected Afghans, leaving the population trapped in a cycle of repeated, protracted crises.[17]

As Emergency, a humanitarian NGO, noted in a 2023 report: “In a country that formerly depended on international aid for 75 percent of public spending, the impact of reduced funding on Afghan civilians, who are bearing the brunt of a rise in poverty and a dearth of essential services, is severe.”[18] The International Committee of the Red Cross was one of the first organizations to sound the alarm, saying in October 2021 that aid groups on their own could not avert a humanitarian crisis, and again in January 2022 that “the humanitarian system cannot replace institutional service delivery systems for 40 million people.”[19]

 

II. Aid Cutbacks and Loss of Funding

After the initial loss of foreign aid in August 2021 caused an economic freefall, donors in response provided a temporary increase in humanitarian aid, some of which went to the health sector. Since the end of 2022, however, international and local humanitarian organizations have experienced funding cuts that have adversely affected health care. The reduction in aid and loss of funding has had a profound and immediate impact on the right to health for people in Afghanistan, while the overarching economic crisis has severely limited people’s ability to meet their needs and pushed them further into poverty. In August 2023, the World Food Program in Afghanistan removed from its assistance programs 18 million people experiencing “serious food insecurity” and 3.4 million people experiencing “critical food insecurity” because funding appeals had fallen short.[20] These cuts came on top of earlier reductions in June 2023 that removed eight million food-insecure Afghans from assistance, and another 1.4 million new and expecting mothers and children from malnutrition treatment because of a downturn in international funding.[21]

Local health NGOs have been hit hardest by funding cuts. Most used to be part of the Sehatmandi program, a US$600 million World Bank-directed program under which the Ministry of Public Health contracted with NGOs to provide healthcare services.[22] After the Taliban takeover and the loss of funding for Sehatmandi, a number of interim measures were put in place, including short-term contracts with NGOs through UN agencies, including the UN Children’s Fund (UNICEF).[23] However the disruptions led some local health facilities to close. As of the end of 2023, UN agencies, multilateral donors, international health organizations, and Taliban authorities had yet to agree on a new health sector strategy, and the role local groups would play in that.[24]

Decisions by governments and international banking institutions not to deal directly with Afghan commercial banks or the Central Bank of Afghanistan because of sanctions imposed by the US and other countries have exacerbated the crisis.[25] Although subsequent clarifications of the sanctions regime explicitly state that humanitarian aid is exempted, as well as most commercial transactions and payment of normal taxes and fees to Afghan government agencies, staff of aid organizations have said that problems with transferring and withdrawing funds have continued.[26] As the international humanitarian medical organization Médecins Sans Frontières (MSF) noted in February 2023: “Economic, banking and liquidity challenges are at the heart of the current humanitarian crisis in Afghanistan and greatly contribute to the difficulties people face in accessing and affording essential services, including healthcare.”[27]

Because of the fear of sanctions, many international banks have often not covered withdrawals by aid organizations. Even when funds have been transmitted electronically into banks, liquidity remains a serious problem for local NGOs, which do not receive payments directly from UN agencies. Taliban authorities have also set limits on withdrawals that have fluctuated over time, further complicating the situation.[28] A staff member of an Afghan NGO said, “Purchasing [supplies] locally is a nightmare with the current banking system."[29]

Loss of Hospital Support

After the Taliban takeover, Afghan hospitals faced a sharp reduction in funds (which had been provided in large part through the former government’s budget), coupled with the loss of staff who had fled the country or stopped working out of fear or cuts in pay. In September 2021, the International Committee of the Red Cross (ICRC) stepped in to replace the Afghan budget funding, providing support to 33 provincial-level public hospitals that were previously funded by the former government’s Ministry of Public Health, paying the salaries of 10,900 Afghan doctors, nurses, and staff, and the costs of drugs, medical supplies, electricity, ambulance services, lab tests, and food for patients.[30] Explaining the move, the ICRC said that it took the decision “to save the healthcare system from collapsing.”[31] The support program lasted two years until the ICRC began to face its own funding shortfall. In April 2023, the Taliban’s Ministry of Public Health assumed responsibility for eight of the 33 hospitals, with other public hospitals anticipated to make the transition in subsequent months.[32] In August 2023, when announcing an end to the program, a spokesperson for the ICRC said, "[T]he ICRC does not have the mandate nor the resources to maintain a fully functioning public health-care sector in the longer term."[33] As of September 2023, the World Health Organization (WHO) had increased its support to the hospitals by supplying essential medicine and supplies, and UNICEF has assumed responsibility for NGO contracts. WHO has urged donors to help sustain the hospitals with humanitarian assistance.[34]

Humanitarian aid organizations working in Afghanistan have told Human Rights Watch that they also plan to close hospitals and reduce operations because of inadequate funding. One official working with an international humanitarian organization said: “All donors have been cutting aid…. We closed some mobile teams because donors cut aid. We may need to close 10 major hospitals in the next six months.”[35] The US Office of the Special Inspector General for Afghanistan Reconstruction reported that in 2023, “262 static and mobile health facilities and 173 mobile health and nutrition teams were discontinued” due to lack of funds.[36]

In response to the impact of the projected shortfall in funding, Dr. Luo Dapeng, the WHO’s Afghanistan representative, said, “For a country already affected by decades of conflict, underfunding of the healthcare system is a critical humanitarian concern.”[37] Even as healthcare facilities have lost funding and have had to downsize in terms of staff, they are seeing an increase in the number of patients. There are several reasons for this. One is an increase in illnesses linked to poor nutrition. In 2022, Afghanistan suffered a severe measles epidemic directly linked to malnutrition among children as well as a drop in vaccinations.[38] Healthcare workers have also reported an increase in diarrhea and respiratory diseases linked to poor nutrition, especially among children.[39]

According to the UN, as of October 2023, an estimated four million Afghans were suffering from acute malnutrition, including over 875,000 children under 5 suffering from severe acute malnutrition, and some 804,000 pregnant and lactating women from under nutrition.[40] The incidence of life-threatening diseases, particularly among children, including measles, respiratory infections, and diarrheal diseases has also increased. In February 2023, WFP said that Afghanistan was at its highest risk of famine in 25 years—not from a lack of food, but from lack of money to buy it.[41]

As the number of primary health facilities has shrunk because of the loss of staff and funds, secondary and tertiary health facilities are seeing patients who should be seen by primary care workers. The head of an international humanitarian organization said:

Due to cuts in funding and no development aid, a fragile health system [like this] can’t respond to the public—there’s no proper [primary] medical care. Twenty-five percent of patients arriving at the emergency room arrive from districts, and the vast majority shouldn’t have come to us. But they have no other option. The increased number of patients overwhelms the facilities—it puts the hospital at the risk of collapse. We need to make sure that people have access to primary health care.[42]

As one example, an aid worker said that of the thousands of births at maternity hospitals in Afghanistan, a quarter were complicated deliveries. “The rest should have found a facility to deliver near home, but they couldn’t.”[43] At the same time, another healthcare worker said, “Women are dying of home delivery because of a lack health services.”[44]

An official with an international healthcare organization said: “Since the Taliban takeover, the health system has been severely impacted. Our family planning clients have increased by 50 percent because they first go to primary health facilities, and those facilities can't provide the necessary care and medicines, so they all come to us.”[45]

The lack of adequate primary health care is also due to Taliban policies. Like their predecessors, Taliban health officials often reveal a preference for bricks-and-mortar healthcare improvements—like tertiary care hospitals—over primary care clinics or community-based care.[46] One healthcare worker said that Taliban authorities’ demands on them to “build a hospital” were often “not realistic,” and they had to “work our way around it and negotiate.”[47]

Relative calm in areas that had seen intense fighting for many years has meant that more people now travel for health care, when in previous years they would not have taken the chance. An official with an international humanitarian organization said:

We have access [now] to areas that we didn’t have access to previously, and now we see that there is a huge need in those areas. Provinces or districts which used to be unsafe [during the fighting] either don’t have a facility or need to strengthen their facility. There is now pressure 0n international NGOs to provide for the population in those places.[48]

Shortages of Medicine and Supplies

Many staff working with local Afghan humanitarian organizations told Human Rights Watch that since the Taliban takeover it has become a challenge to import medicine into the country and that they have faced shortages as a result. Problems with the banking system and frequent disruptions to cross-border trade with neighboring countries such as Pakistan have exacerbated the situation.[49]

The import of pharmaceuticals in Afghanistan has always been poorly regulated.[50] The prevalence of poor quality and smuggled drugs led most international NGOs to bring in their own supplies after 2001. With many medicines increasingly difficult to obtain, smuggling has reportedly increased since 2021, and unregulated pharmaceuticals from China, Iran, India, and Pakistan are widely available in private pharmacies.[51]

One official with an international organization said that while they would rather use local suppliers, the quality of the drugs is a concern: “The Ministry of Public Health’s lab, which is responsible to check the quality of medicines, doesn’t have the necessary material to [run the] tests.”[52]

Some organizations also raised concerns about corruption in the distribution of medicine donated to the ministry. “The right people are not there to distribute and if it goes to private pharmacies, that’s an issue.”[53]

Many local organizations said importing medicine is a problem. Larger humanitarian organizations that bring in their own medicines can ensure quality control, but smaller organizations cannot.[54] One official from an international organization said: “Bringing medicine is not an issue for us, but it is for the local NGOs and private clinics. It’s difficult to import with fewer flights, and humanitarian cargo flights can’t bring enough. Also, there is not enough money to buy.”[55]

Ahmad Naderi, who has worked with a medicine distribution project in Bamiyan since 2014, said, "Our contract is the same, and we still receive the same package, but it isn’t enough [anymore] as our clients’ needs, which are usually local clinics, have tripled since the previous government collapsed. The ongoing humanitarian crisis has impacted everyone’s lives, and people are in greater need of health services and medicines."[56]

Extreme Poverty and Worsening Malnutrition

The dire economic situation in Afghanistan has contributed to extreme poverty and widespread malnutrition, which in turn has had profound effects on the country's already fragile health system. According to humanitarian organizations, malnutrition rates, which were already very high in the last years of the former government, especially among children, have increased.[57] Inadequate access to food, clean water, and healthcare services has also led to a rise in preventable diseases. This has placed a strain on an already struggling health system as it grapples with an increased demand, including greater need for specialized care for people with acute forms of malnutrition. According to the UN, as of September 2023, more than 28 million people—two-thirds of Afghanistan’s population—required humanitarian assistance. More than 15 million Afghans were living in a state of acute hunger, while 2.8 million were experiencing critical or emergency levels of hunger.[58] A staff member for a local humanitarian organization said:

While the World Health Organization does provide some support to families living below the poverty line, their efforts are unfortunately inadequate to cover the vast number of individuals in need. This assistance only reaches a quarter of those facing dire circumstances, leaving a significant portion of the population without the crucial aid they require.[59]

While some organizations are trying to mitigate the crisis, they also confirm that the needs are beyond what they can provide. A humanitarian aid worker in Kabul said:

I met a woman who had a malnourished baby, and she kept coming back to our facility every month, taking medicine and food for the malnourished child while the child was not gaining any weight. While I asked her the reason, she told me that she's dividing the food among three children.[60]

Many people are unable to reach public healthcare facilities because of the financial constraints associated with transportation. Because as in many countries, women and girls are often expected to eat last and less in households, and families are less likely to pay transportation costs and medical fees to access care for women and girls, they are disproportionately at risk of malnutrition and diseases linked to it, while also less likely to receive care. MSF reported that in 2022:

Girls accounted for around 55 percent of admissions to both the outpatient therapeutic feeding programme and the [Inpatient Therapeutic Feeding Centre] ITFC, with mortality almost 90 percent higher for girls than for boys. … When there is not enough food for everyone in a household, women and girls may be deprioritized… a family may seek care faster for a boychild than a girl.[61]

Humanitarian groups have also reported an increase in malnutrition among pregnant and lactating women.[62] The country director of a humanitarian organization in Mazar-e Sharif said that at one of his organization’s clinics, a pregnant woman told him, “We don’t have enough food and only eat bread and tea.”[63]

III. Taliban Violations of Women’s and Girls’ Rights as Obstacles to Health Care

The Taliban have systematically violated women’s rights in most aspects of their lives, including their rights to free movement, to employment in many fields, and access to health care. Women who have sought health care and health care providers have described how these rights violations have created major barriers to their obtaining medical treatment, especially in rural areas, and to their accessing humanitarian assistance, including assistance essential for their health. These barriers violate their right to health and contravene principles of gender equality and non-discrimination, perpetuating inequality.

Bans on Women Working for the United Nations and International Organizations

On December 24, 2022, Taliban officials announced a ban on women working with international humanitarian organizations in Afghanistan, claiming that they were doing so because female staff were not sufficiently observing hijab and workplaces were not fully segregated by gender.[64] The Taliban’s Ministry of Economy announced the ban in a letter to the Agency Coordinating Body for Afghan Relief and Development (ACBAR), which represents over 180 NGOs working in Afghanistan. In the letter, the Taliban authorities threatened to revoke the operating licenses of organizations that did not comply with the ban.[65] On April 4, 2023, Taliban authorities clarified that this ban also barred Afghan women from working in UN offices in the country.[66]

In response to international pressure to reverse the ban, Taliban authorities have delimited exemptions for women to work in some positions in the fields of health, nutrition, and education.[67] However, the Taliban have never set out these exemptions in written form, leading to concern among some aid workers and activists that they are subject to interpretation by local Taliban officials and could be withdrawn at any time. “Nooria S.,” a healthcare worker in Chimtal district of Balkh province said, “We work today but there’s no guarantee that we will work tomorrow.”[68]

Moreover, Taliban security forces and officials with the Ministry for the Propagation of Virtue and the Prevention of Vice have also at times enforced the ban even in usually exempted positions in these sectors, as described below. Afghan women employed by the UN and international organizations in health and education have continued to face restrictions on their freedom of movement and dress.

Mahram and Hijab Requirements

On December 26, 2021, the Taliban issued a directive stating that women and girls travelling “long distances” should not be allowed in taxis or public transport unless accompanied by a male relative acting as a chaperone (mahram).[69] The directive specified the distance as 72 kilometers, but some Taliban officials and security forces have interpreted it to mean much shorter distances as well, including any travel outside the home—such as commuting to work or traveling to get medical care. In Ghazni province in January 2022, some Taliban officials prevented women from attending healthcare appointments unless they were accompanied by a mahram.[70] On May 7, 2022, the Taliban issued another directive stating that women and adolescent girls should cover themselves from head to toe, including the face, and avoid leaving their homes. It said the male relatives of women and girls would be held responsible and face punishment in cases of women and girls not dressing “appropriately.”[71]

As a result, in some provinces, female staff working for NGOs have been able to work only if they are accompanied by a mahram during working hours. For example, an official with an NGO in Kandahar told Human Rights Watch that their female staff needed to have a mahram accompanying them all day. He said that female patients also need to be accompanied by a mahram; without one they would be denied access to healthcare services. Other healthcare providers have described similar experiences. In a 2023 report, an MSF staff member said:

Already I see that the Taliban at checkpoints looking for any excuse to prevent women from moving freely. For example, my sister was sick recently and when she was travelling to our hospital for a check-up, they did not allow her to go because she didn’t have a mahram. She stood there for about 50 minutes, outside in the cold. Then my brother came, and they allowed them to leave.[72]

“Sharifa M.,” a doctor in Samangan, said: “The Taliban have instructed us not to treat any female patients who is not accompanied by a mahram or is not in full hijab.”[73] These restrictions seem to be implemented with particular severity outside major urban areas in the southern provinces and rural areas of Afghanistan. The requirement that a woman bring a mahram with her to healthcare appointments not only obstructs her ability to access health care but also violates her right to privacy by likely obliging her to disclose what may be private medical information to the family member.

In some hospitals and clinics, both female patients and healthcare workers need to be accompanied by a mahram.[74] A humanitarian organization in Zabul said that all their female staff colleagues generally need to be accompanied by a mahram.[75] As a result, skilled female healthcare workers cannot work in many areas because they do not have a mahram to accompany them while travelling or to places of work.

Male doctors are not allowed to see female patients. Families may also not allow their female relatives to seek medical care if the medical staff are all male.[76] An NGO staff member said that two months after the Taliban takeover, Taliban security forces beat a male doctor “for providing health services to female patients in a village of Samangan province.”[77]

While some organizations have managed to continue their operations without adhering to the mahram rule, a country director for one organization made clear that to do so is precarious:

The policy is for women to be accompanied by a mahram when they work. In cases where some organizations, including ours, have been able to negotiate on the local level and continue operations without these restrictions, that’s a violation of the Taliban’s policy, not the rule.[78]

Humanitarian organizations also raised concern about the lack of clarity on these rules and the fact that they can differ depending on location. For example, in some provinces, women healthcare staff can move around without mahrams. In others, humanitarian aid groups need to establish segregated offices separating female and male staff.

In Kunduz, clinics with all-women staff—from doctors to pharmacists to reception—have not faced any problems.[79] One aid official described the variations: “In Khost, our female staff are required to wear burqas while on the job and a face mask, and their offices should be separated from male staff. In Nangarhar, we should have entirely separate buildings for female and male staff.”[80]

A staff member of another organization said:

In Faryab and Jawzjan, the Taliban issued an appreciation certificate recognizing the work of female workers to our provincial coordinators, who are female. But in Kunduz, the Ministry for the Propagation of Virtue and the Prevention of Vice didn't allow our female staff to attend meetings with the health department. In other provinces where the Taliban need to bring their wives for family planning, they allow our female pharmacists, technicians, and receptionist to work.[81]

The director of an international humanitarian organization said that in one province, his organization was able to negotiate with local Taliban authorities to allow female staff to be picked up by their mahrams after working hours ended, so as to not have them stay with them all day.[82]

Over the years, NGOs have operated mobile clinics in rural areas, or provided transportation for staff to travel to rural areas to provide health care. The Taliban’s restrictions have severely limited mobile services to prevent female staff from traveling in vehicles and to reduce door-to-door services that involve community health practitioners visiting private homes. Taliban security forces have sometimes stopped mobile teams at police stations and checkpoints to see if staff have mahrams. According to humanitarian organizations, officials of the Ministry for the Propagation of Virtue and the Prevention of Vice have established checkpoints in some areas specifically for the purpose of checking for mahrams and hijabs. An official with a humanitarian organization said: “We had cases where if one person doesn’t have mahram, they [Taliban authorities] sent us letters, saying that if we don’t observe the rule, they will stop our activities.”[83] In some areas, Taliban officials have required mahrams to have an ID card to identify himself as the mahram of a specific female employee; the Ministry for the Propagation of Virtue and the Prevention of Vice has issued these cards in some districts but not uniformly. [84] An official with an international humanitarian organization based in Afghanistan said:

Because women can’t go to male [healthcare workers], in Logar province, our mobile team has to travel three hours distance there and back; they can’t go without mahram, which is a big problem. There are female healthcare workers who are very skilled but don’t have a mahram and can’t work.[85]

One health worker said that her organization tried to negotiate having a mobile team made up of a driver, midwife, and nurse, but the Taliban stopped them.[86] The result has been that communities in remote areas no longer have access to these services. A health worker at an international aid group said: “Before the takeover, we had 2,500 female staff who used to go house to house, providing community services, and distributing hygiene kits. Now all these programs including our mental health programs have stopped.”[87]

Organizations have also raised concerns about a lack of understanding about the importance of community health services by the Taliban. An aid worker said: “We are not allowed to distribute hygiene kits; a lack of those leads to increased urinary tract infections (UTIs) and problems with childbirth…. they don’t understand that this is not a luxury; it’s a basic need for women.”[88]

In one province, the Taiban have told UNICEF to train men on breastfeeding, and then those men could train their wives at home.[89]

An official with a humanitarian organization said the loss of community health services was likely to lead to outbreaks of preventable diseases:

We now have to restrict ourselves in stopping at our delivery points [rather than go to homes], and we are beginning to see our numbers [of patients] decreasing. …They can’t come to us and the number of diseases are going to increase. Infectious diseases are preventable on a community level but with these restrictions it’s difficult.[90]

The restrictions have also added to costs. According to a staff member of an international NGO in Kabul, normally, “a mobile team consisted of a counselor, midwife, nutrition expert, and doctor. Now we need to have one mahram for every one of them. We need to hire another car, that means extra cost, and we also need to provide per diem for their mahrams.”[91]

Organizations have also reported that the Taliban have advised them to transfer their mobile teams to established clinics, even where none exist. The country director of an international NGO in Afghanistan said that not only did they not have the capacity, the donors would not be flexible for such changes. “We can’t construct places. … We spend so much time trying to explain what we do and why we do it.”[92]

The Taliban’s new restrictions have compounded longstanding problems of access to medical care in rural areas. In remote areas like Daikundi, where access has always been difficult because of poor roads, or in Badakhshan where heavy snow often makes the roads impassable, women already needed to travel long distances to access health services. Because of the mahram requirement, this has now has become more difficult.

Imposition of hijab rules has also impeded access to health care. A staff member at a humanitarian organization said:

The situation is really bad. My sister is in Samangan and she’s the only healthcare trainer. The Taliban went to her clinic and my sister wanted to speak to them. They put a curtain in front of her. If someone comes and is dying and doesn’t have full hijab, you can’t treat her.[93]

 

IV. Education Ban and Shortage of Female Healthcare Workers

On December 20, 2022, Taliban authorities banned women from public and private universities, including medical training programs. The ban has exacerbated the crisis created by the prohibition on girls’ attending secondary school – even if girls and women were allowed to resume higher-level education programs, none would currently have the high school educational requirements for medical training. As the head of one international humanitarian organization said, “If patients can’t get treatment today, what will happen in the future when half of all potential medical students are not allowed to study?”[94]

As of January 2024, none of the university programs had reopened for women, although midwife and nursing training programs run by NGOs have continued.

The Taliban’s bans have compounded longstanding shortages of female doctors, nurses, pharmacists, and other healthcare professionals, a deficit acutely felt in rural areas.[95]

The lack of female healthcare providers has had dire consequences, particularly given Afghanistan's already high rates of maternal mortality and the prevalence of preventable diseases among women and children. According to WHO, even before the Taliban takeover, Afghanistan had one of the highest rates of maternal deaths per capita in Asia.[96] As of 2023, the ranking stayed the same, but healthcare officials have raised concerns that the failure to train new female healthcare professionals and specialists in obstetrics and gynecology means that the maternity death rate could rise.[97]

Hospitals and clinics in Afghanistan have reported their difficulties in hiring female doctors and other health professionals. The director of an international health NGO said of its operations in Kandahar:

We had to announce a female doctor’s vacancy 20 times, and yet there’s no one to fill the position. …No female doctor has graduated in the past two years. I am scared of the day, like when in 2005, when we used to bring doctors from Tajikistan, that we will end up this way. We can’t find qualified doctors.[98]

An organization in Paktika had to re-advertise one female doctor vacancy many times in six months, and as of January 2024 still had not been able to fill it because of the lack of women applicants willing to work in rural areas. [99] In addition, women who had recently completed medical school but have been unable to graduate has exacerbated the problem. The country director for an international aid group said, “We have hundreds of qualified female healthcare workers who are ready to join the system but can’t because of the Taliban’s restriction on them taking their exit [licensing] exams.”[100]

An international healthcare organization representative said that most female doctors in Afghanistan were trained to work in maternity wards, leaving a lack of female doctors in other specializations. This shortage “has far-reaching implications for women's health care and access to specialized medical services.”[101]

The shortage of female healthcare professionals poses a significant threat to the sustainability of Afghanistan's public health system. The ban on girls' education has a cascading impact on the healthcare system, particularly for women. Preventing girls from attending secondary school deprives them of knowledge about basic health care as well as the education needed to progress to tertiary levels. Women who lack access to education may be less able to make knowledgeable decisions about their own or their children’s health, which could contribute to insufficient or delayed care.

This restriction has contributed to unequal access to health care, barriers to seeking medical assistance, and a shortage of qualified healthcare workers. The country director of an international humanitarian organization said, “Afghanistan has always had a shortage of qualified female doctors and nurses, and with the current ban on education for women, it’s going to be a disaster for the foreseeable future."[102]

 

V. People with Disabilities and Mental Health Conditions

Among those most affected by Afghanistan’s economic crisis are people with disabilities. Because of aid shortfalls, many NGOs no longer provide the few targeted services some of them had previously offered specifically for people with disabilities. The Taliban’s policies banning women and adolescent girls from traveling, and in some cases working, without a mahram have also had a particularly detrimental impact on women and adolescent girls with disabilities and on women supporting others with disabilities. These developments underscore the urgent need for targeted interventions to safeguard the rights of the most marginalized groups and ensure their equal access to essential services, in accordance with international human rights standards.

Afghanistan has one of the largest populations per capita of persons with disabilities in the world. A 2019 Asia Foundation survey found that roughly four out of every five Afghan adults, and one out of five children, had a disability, whether physical, sensory, intellectual, or psychosocial.[103] Afghanistan’s prolonged decades-long conflict resulted in over one million Afghans experiencing limb amputations and other impairments affecting mobility, sight, or hearing.[104] A 2005 study found that 67 percent of Afghans reported experiencing the effects of trauma or other psychosocial conditions, with the unemployed, older persons, and widowed women particularly affected.[105] The study also noted that women with disabilities, regardless of the cause, had a higher prevalence of other mental health conditions.[106] Entrenched discrimination has meant that persons with disabilities have faced significant obstacles to education, employment, and health care, rights guaranteed under international human rights law. 

Even before the Taliban takeover, a lack of institutional support and qualified practitioners, as well as inadequate community awareness impeded the provision of treatment and rehabilitative services to people with disabilities.[107] In 2012, Afghanistan ratified the Convention on the Rights of Persons with Disabilities and its Optional Protocol. In 2013, the Afghan parliament approved legislation, the Law on Rights and Privileges of Persons with Disabilities, ensuring the rights of persons with disabilities to participate actively in all aspects of society. However, there were very few specialized health or other support services, such as physical rehabilitation, for people with disabilities in Afghanistan, and the demand far outstripped available resources. Neither the previous government nor donors had specifically prioritized ensuring that the health services and other programs they funded were accessible to people with disabilities. NGOs have been supporting some remaining services for people with disabilities, including a school for people with visual disabilities in Kabul, but because of funding cuts many services have shut down.

In addition, as Fayeza Ahmadi, who formerly ran an NGO to provide services for people with disabilities, said, most of these programs were short term. The departure of skilled professionals after August 2021 has exacerbated the situation, particularly for those people requiring services for physical rehabilitation. [108] Remaining physical rehabilitation services are few and not widely available or accessible. Because many patients have to travel long distances to get services, many forego them altogether. Traveling to obtain services has for many families been complicated by poverty, poor quality roads in remote areas, and above all the cost of transportation. For women and girls, the mahram requirement created an additional obstacle.

The healthcare organization HealthNet estimates that since the Taliban takeover, one in two Afghans has experienced stress, anxiety, or other forms of psychological distress as a result of political violence, instability, and poverty.[109] Access to mental health support has diminished because of a loss of funding from foreign donors for health care in general, with mental health services generally the first to be cut.[110] A counselor based in Kabul said that “even before the Taliban takeover, there were few donors to provide mental health services in major cities. Now most of them are gone, while people are in in greater need.”[111] A lack of female health service providers has meant that women and girls with disabilities have less access to services. UN Women has worked with local partners to make some psychosocial support services available to women, whether in-home or by telephone.[112]

Organizations report that most of the skilled workers who used to work with people with disabilities left the country during evacuations or after the takeover due to security concerns and the economic crisis. There are also fewer resources for prosthetic devices, medicines, and other supplies, and the prices have increased, putting them out of reach for patients and small organizations working with people with disabilities. A psychologist in Herat said that medicines for mental health care are hard to find:

No one imports medicine for mental health, for example, pills that can make the life of a person who experiences anxiety easier. From every 10 cases that I see every day, 6 of them need antidepressants, which you can’t find easily in Afghanistan anymore.[113]

Women and girls with disabilities face compounded challenges due to societal norms, limited support, and Taliban restrictions. Although travel in Afghanistan’s provinces has become easier for men since active fighting ended, the requirement that women and adolescent girls have a mahram has severely hampered mobility for all, including those with disabilities. “Ahmad S.,” who works with an NGO in Mazar-e Sharif, said: “We had beneficiaries from all the provinces, now most of those women can’t come because they need to have a mahram.”[114] Societal norms around gender and disability also limit the family support that women and girls with disabilities receive, leaving them less likely to get necessary health care and other services.

The Taliban’s policies banning women from working for international humanitarian organizations except in some positions in health, nutrition, and education has been an additional factor reducing targeted services for people with disabilities. “Aziza A.”, who had been the deputy director of an organization in Kabul that provided assistance for people with disabilities throughout Afghanistan, has not been able to work in her position since the Taliban issued their ban on women working for international NGOs. “I have worked for the Kabul orthopedic center for more than 20 years,” she said. “Now I can’t be deputy director anymore.”[115]

The Taliban’s policies banning girls and women from secondary and university education and limiting their ability to work have reportedly led to a rise in depression and anxiety among Afghan women and girls, including suicides in some cases.[116] Healthcare workers have reported that many women and girls seeking treatment for other conditions also report feeling anxiety, stress, and other mental health concerns related to restrictions on their freedom of movement and other rights abuses. Women also said their mental health was being affected by experiences of poverty. A local NGO official said: “Most women who come to us for treatment are dealing with several psychological issues but in Afghanistan, mental health is the last thing people think about, and there’s very limited availability of services too.”[117]

Stigma remains another huge barrier blocking people from seeking mental health support. Mental health is considered a taboo topic, and people often hide their concerns and avoid seeking help from their families or from a professional. This longstanding stigma is exacerbated by Taliban restrictions. “Mehria A.”, a woman in Nangarhar, has experienced depression and said that she prefers to be able to seek assistance by herself. However, with the Taliban’s restrictions, she needs to take her brother with her as her mahram when she goes to clinics. “My family won’t understand,” she said. “I wish there were confidential services available for women so I could seek those.”[118] “Palwasha P.”, who has physical disability said, “Poverty and disability are each other’s complement. If they both hit you, it would affect you double. Especially if you are women. … [F]amilies prefer not to take women to healthcare services and if you have disabilities, that’s even worse.”[119]

Another concern that organizations have raised is the lack of any dedicated financial assistance for people with disabilities. Before the Taliban takeover, Afghanistan’s former government provided a small stipend (between US$32 and $66 a month) to people who had acquired a disability as a result of a conflict-related incident.[120] People who had been born with or acquired a disability for reasons other than conflict were not eligible for any financial assistance from the government.

Some Afghans who had received this stipend told Human Rights Watch that after the Taliban takeover, their names have been removed from the official disability list, which used to give them an allowance of up to 60,000 afghanis [$800] a year depending on their disability. Others who had been receiving disability allowances as military veterans and had acquired disabilities as soldiers were afraid to collect their allowance because their identities could be revealed, putting them at risk. According to one disability rights activist, Taliban authorities in charge of the ministry have stopped providing disability certificates to single women and girls.[121]

“Asma J.”, who has previously worked for an NGO in Kabul and has a physical disability, said that since the Taliban took control, she experiences psychological distress:

I went to the Ministry of Economy to extend my disability certificate, and they treated me as if I were not a human being. They didn’t let me sit in the front seats in the lobby; I had to sit at the back. Both my legs were injured in a mine explosion, but I still had to walk two floors and the ministry staff person who was supposed to help me had his back turned to me [so as not to see me]. I used to have a job. Now I have no right to education as a woman—what do I want this life for?[122]

 

Acknowledgements

This report was researched and written by Fereshta Abbasi, Afghanistan researcher at Human Rights Watch. Patricia Gossman, associate Asia director at Human Rights Watch, provided divisional review. Heather Barr, associate director, and Sahar Fetrat, researcher, with the Women’s Rights Division; Zama Neff, director of the Children's Rights Division; Jonas Bull, assistant researcher, and Bridget Sleap, senior researcher, with the Disability Rights Division; and Matt McConnell, researcher with the Health and Economic Justice and Rights Divisions; provided specialist reviews. James Ross, legal and policy director, and Tom Porteous, deputy program director, provided legal and programmatic review respectively.

Editorial and production assistance was provided by Robbie Newton, senior coordinator for the Asia Division. Additional production support was provided by Travis Carr, digital publications officer. This report was prepared for publication by Jose Martinez, administrative officer, and Fitzroy Hepkins, administrative senior manager.

Our deepest thanks to our external reviewers, Bill Byrd, an economic expert on Afghanistan, Kate Clark, co-director of Afghanistan Analysts Network, and Paul Fishstein, non-resident fellow at the New York University Center on International Cooperation, for their invaluable insights. The usual disclaimers apply, and any inadvertent errors remain ours alone.

We would also like to acknowledge the assistance we received from nongovernmental organizations, both domestic and international, working in the field of health care in Afghanistan, and from all those who agreed to be interviewed for this report. Their willingness to share their accounts and views significantly enriched our analysis. To respect their security, their identities have been kept confidential.