Research Papers

By Sakhi Bayramli (MS.c.) * Introduction Following the year 2002, despite deep structural challenges, lingering insecurity after three decades of civil war that had destroyed much of the health sector infrastructure, and severe economic constraints, Afghanistan’s health system – benefiting from extensive support and attention from the international community- was able to provide at least basic and primary health services to a large portion of the population. The expansion of primary healthcare facilities, the rollout of the Basic Package of Health Services (BPHS), the training of health personnel- especially midwives- and relative improvements in maternal and child health indicators were among the major achievements of this period (WHO, 2020; World Bank, 2019). However, following the unexpected political developments of 2021 and the collapse of the Islamic Republic of Afghanistan in August of that year, the country’s health system faced a multidimensional collapse. Widespread restrictions on women’s education and employment, the sharp reduction or complete suspension of international aid to the health sector, serious weaknesses in health sector management, and the mass emigration of skilled health professionals have all led to a drastic decline in access to basic health services, particularly for women and children in remote areas (UNICEF, 2022; UNDP, 2023). Methodology and Research Design This article is part of a sixty-page study that was accepted in September of this year as a Master’s thesis under the supervision of two international experts from the University of Bonn in Germany and the United Nations University in the Kingdom of Belgium. Using a comparative approach, the research examines the status of Afghanistan’s health system and women’s vulnerability before and after 2021. The study is based on field interviews with international experts associated with Afghanistan’s health sector in Geneva (Switzerland), Istanbul (Türkiye), Brussels (Kingdom of Belgium), and Bonn (Germany), as well as an online survey conducted between January and September 2025, which received twenty-three responses from inside and outside Afghanistan. 1. Women’s Access to Health Services Before and After 2021 Prior to 2021, Afghan women’s access to health services- although still insufficient- was on an improving trajectory. The increase in the number of female doctors and midwives, the expansion of health facilities, and sustained support from international organizations enabled millions of women to access antenatal and postnatal care, family planning services, and vaccinations (WHO, 2019; World Bank, 2020). After August 2021, restrictions on the employment of female doctors, the requirement of a male guardian (mahram) for visiting health facilities, and the closure of universities to girls significantly reduced women’s access to healthcare. In many remote and relatively conservative provinces-including Jawzjan, Faryab, Bamyan, Kandahar, Logar, Ghazni, and Farah-the lack of female health personnel has effectively deprived a large proportion of Afghan women of essential health services (UN Women, 2022; Amnesty International, 2023). 2. Neonatal Mortality Before and After 2021 Before 2021, although Afghanistan had one of the highest neonatal mortality rates in the world, it was nevertheless experiencing a gradual decline in this indicator. Improved maternity services, an increased number of trained midwives in rural areas, and expanded childhood immunization were key factors contributing to this downward trend (UNICEF, 2019; WHO, 2020). After 2021, however, the closure of health facilities, shortages of quality medicines, reduced maternal and child health services, and the widespread increase in poverty and child malnutrition have caused neonatal mortality rates to rise again. The absence or inadequacy of health education programs for families has further exacerbated this crisis (UNICEF, 2022; Save the Children, 2023). 3. Human Resources in the Health Sector Even before 2021, Afghanistan faced a severe shortage of health professionals. Nonetheless, international training programs and financial support had led to a gradual increase in the number of doctors, nurses, and midwives, although these figures remained below internationally accepted standards until the final days of the republic (WHO, 2018; World Bank, 2020). After 2021, the mass departure of doctors (both women and men), the ban on women’s education, and restrictions on their employment resulted in a sharp decline in active health personnel. In remote provinces, this situation has, in some cases, led to the complete closure of health facilities (UNDP, 2023; WHO, 2022). One key indicator used to assess the quality of a country’s health system is the number of health personnel per ten or one hundred thousand population. Although the World Health Organization (WHO) does not recommend a single fixed global standard for the number of health workers per 10,000 people – given variations in country contexts, health needs, skill mix, and equity in access, and therefore does not officially recommend such a figure for national planning – it does estimate that at least 230 core health workers per 100,000 population are necessary to deliver essential services and achieve the 2030 Sustainable Development Goals (SDGs). By contrast, Afghanistan had only about four to five doctors per 100,000 people even before 2021, and after 2021 this figure has fallen to fewer than two doctors per 100,000 in some provinces, which is several times lower than global standards (WHO, 2022). 4. Maternal Mortality Before and After 2021 Even prior to 2021, Afghanistan had one of the highest maternal mortality rates in the world. Nevertheless, the overall trend was moving toward relative improvement. Increased skilled birth attendance and partial access to emergency obstetric services played an important role in this decline (WHO, 2019; UNFPA, 2020). After 2021, restrictions on the employment of female doctors, reduced maternity services, and an increase in unsafe home births have significantly heightened the risk of maternal death. Many women avoid seeking care due to the absence of female doctors or restrictions on movement without a Mahram or a male guardian (UN Women, 2022; Human Rights Watch, 2023). This situation has also had a direct impact on child mortality, with under-five mortality rates in 2021 reported at approximately 56–58 deaths per 1,000 live births (UN IGME, 2021). 5. Core and Aggravating Factors Behind the Collapse of Afghanistan’s Health System The closure of universities to girls severely threatens the future of Afghanistan’s health workforce and health services, … Read more

This e-paper is co-authored by Abdullah Athayi, the co-founder and Head of Research at Bakhtar Institue. The paper is originally published at Heinrich Böll Foundation‘s website here. Abstract: 15 August 2021 marked the start of a new chapter in Afghanistan after all international troops were withdrawn and the Taliban took over the country. The past 20 years have seen some gains in human rights and women’s rights and the emergence of the Afghan youth as a socioeconomic and political force. The humanitarian situation worsened further in the second half of the year, due to both the ongoing conflict and the economic crisis that has hugely affected all Afghan citizens, in particular Afghanistan’s youth. Many young Afghans were evacuated to other countries, and those who remain in Afghanistan face many challenges, including no access to education, financial hardship and unemployment. This e-paper is written based on interviews conducted with young activists, journalists, human rights defenders and academics from Afghanistan (all under the age of 35), who have been actively involved in the process of democratisation and committed to liberal values over the past 20 years in Afghanistan; it highlights the twenty years of achievements by Afghan youth and explores their hurdles and challenges under the rule of the Taliban’s de facto regime. (Below you can read and download the full paper)

This e-paper is co-authored by Dr. Mustafa Nasery, the Co-founder and Director of Bakhtar Institute, and Mr. Abdullah Athayi, the co-founder and Head of Research at Bakhtar Institute. Abstract: Following a quick overview of the situation before the collapse of the Afghan republic on August 15th, 2021, and an assessment of the past one year under the control of Taliban, this research explores possible options for the engagement of international community with Afghanistan under the Taliban control. It particularly looks at three main options of full-engagement, condition-based engagement, and disengagement. To provide a realistic picture from the ground for a constructive engagement, the research defines and analyzes the pros and cons of each option, and briefly talks about the consequences of the continuation of current situation for both Afghanistan and the international community. The research aims to navigate major perspectives of various groups in the aftermath of Taliban’s takeover and provide constructive intervening options for international community, including international organizations to preserve the minimal achievements of the last two decades and transitioning peacefully from this critical juncture. The paper has been written based on interviews with activists, politicians, researchers, lecturers, and representatives of negotiation teams both inside and outside Afghanistan. Wherever possible, observations and literature review were embodied to consider and analyze all important aspects. (Below you can read and download the full paper)