J. Stephen Morrison and Leonard Rubenstein. "Pulling Afghanistan back from the Precipice—without Capitulation." CSIS Commission on Strengthening America's Health Security, Center for Strategic and International Studies, October 26, 2021. Accessed February 13, 2023. https://healthsecurity.csis.org/articles/pulling-afghanistan-back-from-the-precipice-without-capitulation/
Two months after the Taliban rushed to power, Afghanistan is hurtling toward economic chaos, the collapse of its health system, and a runaway humanitarian emergency. Time is running out. A brutal winter has begun that threatens starvation on a mass scale. The World Food Program (WFP) and Food and Agriculture Organization project that over half of the population, an estimated 22.8 million people, will reach crisis-level food insecurity by the first quarter of 2022. If left unchecked, such a scenario will do extraordinary harm to Afghanistan’s 38 million citizens, externalize the crisis through a surge of refugees, and allow open running room for the spread of Covid-19 and polio.
The United States and other donors, shaken by the debacle of the U.S. withdrawal and fierce criticism from their respective domestic oppositions, are only offering immediate stop-gap funding for Afghanistan’s emergency needs and temporary funding of its health services. The European Union has pledged 1 billion euros in emergency assistance to Afghanistan and its neighbors. The UN Development Program (UNDP) has launched a trust fund that it hopes will avert economic implosion if successful in attracting $667 million over the next year. Germany has pledged 50 million euros, while the Biden administration, it is hoped, will shortly release the $64 million it has pledged. The UNDP aspires through its efforts to cover the expenses of 25,000 Afghan health providers, supported by UN emergency funds and $15 million from the Global Fund to Fight AIDS, Tuberculosis and Malaria.
These recent, urgent measures are important but fall short of long-term sustainable financing, management, and oversight of the health sector. Far more is needed to avoid a collapse of Afghanistan’s health system that reverses 10 years of gains in safe childbirth, life expectancy, and infant and child mortality. Today, more than 80 percent of key health facilities have ceased to operate while rising numbers of skilled health workers have already exited or are actively looking for a way out of the country.
How to explain Afghanistan’s gathering tragedy? An extreme gap separates the Taliban and the West. And up to now, there has been no will and no evident process through which the West and the Taliban can work together to maintain essential services.
The Taliban, though recognizing the need to avoid health service implosion, remain stuck in maximalist positions across a range of sectors, demanding that Western donors provide funding for services under their control. They lack knowledge and skill in both governing and running actual public services and are accustomed to using coercive threats and violence against nongovernmental organizations (NGOs) operating health services to control hiring and programmatic decisions.
The United States has frozen $9.5 billion in reserves and, along with the European Union, other donors, and the World Bank and International Monetary Fund, has suspended bilateral and multilateral flows that previously accounted for 80 percent of the Afghan budget. That aid included funding for the Ministry of Health’s health sector reforms and contracted services run by NGOs. They will withhold the release of essential support until there is satisfaction on inclusive governance, protection of the rights of women and girls, progress on expatriation of Americans and loyal former Afghan allies, and proof of severance of Taliban ties to al Qaeda and more effective action by the Taliban to contain the Islamic State Khorasan Province, also known as ISIS-K. The lone exception is modest humanitarian assistance under UN leadership to meet urgent and immediate needs.
Influential regional neighbors share many of the West’s concerns for inclusivity, denial of expanded havens for terrorists, and the imperative to forestall mass outflows of refugees. But even if these neighbors conclude that the West’s stance is too rigid, if Afghanistan is to avoid ruin, Qatar, Pakistan, Iran, and Russia are in no position to fill the West’s shoes in terms of the financing and stewardship of health services. China, despite its wealth, has signaled no interest in assuming significant financial commitments in Afghanistan.
This daunting reality notwithstanding, there is still reason to believe that the situation in Afghanistan is not irredeemably hopeless and that new partnerships and work-arounds, however imperfect, could be instituted that help the health system avoid a hard crash—without compromising core Western values and interests.
In Yemen, Syria, North Korea, and Zimbabwe under the rule of Robert Mugabe, the international community turned to a variety of creative improvisations to meet basic needs and keep health systems, communities, and economic life afloat by channeling funds through interim trust funds and the United Nations. Agencies such as the World Health Organization (WHO) and United Nations Children’s Fund (UNICEF) were operationally and fiscally responsible for providing finances to local and international NGOs, setting standards and priorities, and maintaining monitoring and oversight. These arrangements tacitly or explicitly required some level of concurrence and input from the government in power, but they avoided vesting funding or policy decisions in the government itself. The international community should take a page from these precedents.
Health is one sector in Afghanistan where such an approach might be successfully applied to sustain the dramatic achievements of the past two decades, when the European Union, the World Bank, and the United States jointly invested $200 million per year through the Sehatmandi project, which built up the capacities of 2,300 hospitals and clinics, raised life expectancy by 10 years, and cut maternal mortality by half. In many of Afghanistan’s 34 provinces, the project managed to maintain relationships with shadow Taliban authorities, albeit subject to forced closures, kidnappings, and other uses of coercion. The 11 Afghan and two international NGOs that did the actual work are still in place, the majority of their staff women who are able to continue working. The same is true of the national polio infrastructure created and sustained by the Global Polio Eradication Initiative, which over the years and recently has gained the cooperation of the Taliban. One promising signal is the Taliban’s recent agreement to permit the resumption of a polio vaccination campaign.
Several major international institutions remain operational on the ground in Afghanistan—the UNDP, WFP, WHO, and UNICEF. The Global Fund has maintained important funding, and service and coordinating agencies—including the UN Office for the Coordination of Humanitarian Affairs; Gavi, the Vaccine Alliance; and the International Committee of the Red Cross—have sought ways to continue work in Afghanistan. Indeed, the leadership of most of these organizations has appeared in recent weeks in Kabul.
Drawing from this array of actors and legacy programs, a focused partnership consortium could be formed, dedicated to preserve health gains, including on polio; replenish women’s employment in the health sector (where brain drain has been acute); and strengthen women’s access to health services. The consortium would substitute for the Ministry of Public Health, combining technical, policy, and operational capacities, thus avoiding channeling assistance directly through a Taliban-controlled government. The arrangement could also provide some leverage in limiting coercion and violence inflicted on health NGOs.
Success will rest on a number of factors. The most elemental will be leadership and investment by the United States and its allies that demonstrate a resolve to stand up against political opponents at home in the United States and elsewhere who remain adamantly opposed to any financial support that even indirectly benefits the Taliban. To avert a human catastrophe in Afghanistan, where the United States and its allies still have some moral duty, requires a commitment to accelerate focused, quiet dialogue that forges a pragmatic mechanism to save lives over the long term and win endorsement from regional neighbors. An incremental, transactional approach, whereby external support is allocated and increased as certain basic benchmarks are met and verified through independent and neutral parties, can deliver reliable results. We can anticipate a string of problems over operational, personnel, and programmatic issues. Yet developing safety and security mechanisms, engaging agencies that have already developed productive relationships with the Taliban, demanding close monitoring, and ensuring strong fiduciary and contract capacities by the consortium—all of these actions can sustain services and build confidence.
The scheme proposed here is not a concession to the Taliban. It is an answer to the urgent threat of massive human suffering and loss. Taking this route can save countless lives, including those of children and Afghan women needing critical services for safe childbirth and other reproductive support. It can stem the erosion of the health workforce, a consequence borne disproportionately by women, who make up the majority of health providers. In the meantime, of course, the United States and its allies can continue, as they should, in pressing the Taliban forcefully for inclusive governance, the rights of women and girls, the outmigration of Afghan allies, and verifiable action against al Qaeda and ISIS-K.
Stephen Morrison is senior vice president and director of the Global Health Policy Center at the Center for Strategic and International Studies in Washington, D.C. Leonard Rubenstein is professor and director of the Program on Human Rights and Health in Conflict at the Johns Hopkins Bloomberg School of Public Health.
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