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, and in the medium to long term will lead to a serious decline in the number of female doctors and midwives. At the same time, weak governance and the assignment of key health sector responsibilities to non-professionals have significantly reduced the effectiveness of the health system (UNDP, 2023; WHO, 2022).
Moreover, the gradual reduction or complete suspension of international aid – due to the absence of a government recognized by the international community- has resulted in the closure of hundreds of clinics and even regional hospitals. This situation, combined with an increase in natural disasters such as floods and earthquakes, has led to the spread of communicable diseases, severe child malnutrition, and a sharp decline in health services in Afghanistan’s remote areas (OCHA, 2023; UNICEF, 2022).
6. Conclusion and Recommendations
The collapse of Afghanistan’s health system after 2021 is the result of a complex combination of political, structural, and economic restrictions that have disproportionately harmed women, children, and residents of remote areas. Without fundamental reforms and urgent international engagement and support, this situation risks turning into a sustained and dangerous humanitarian crisis – not only for Afghanistan but for the wider region.
7. Recommendations
1. Reopening universities to girls, particularly in medical fields.
2. Reopening girls’ secondary schools beyond grade six.
3. Allowing female doctors to work without the requirement of a mahram.
4. Assigning managerial and technical health sector responsibilities to qualified professionals.
5. Attracting domestic and foreign investment to establish and strengthen health facilities in remote areas.
6. Increasing international assistance, especially for women’s and children’s health.
References
1. World Health Organization (WHO). (2018–2022). Afghanistan Health Profile.
2. World Bank. (2019–2020). Afghanistan Health Sector Review.
3. UNICEF. (2019–2022). Maternal and Child Health in Afghanistan.
4. UNFPA. (2020). Maternal Health in Fragile Settings.
5. UN Women. (2022). Women’s Access to Health Care in Afghanistan.
6. UNDP. (2023). Afghanistan Human Development Update.
7. Human Rights Watch. (2023). Health and Human Rights in Afghanistan.
8. OCHA. (2023). Afghanistan Humanitarian Needs Overview.
* Sakhi Bayramli is a distinguished scholar-practitioner in the fields of Global health policy, health diplomacy research, and human rights. His academic formation spans International Relations, Global Health, and Political Science. As the co-founder and board member of the Bakhtar Institute and a participant in various research projects with the United Nations University, Mr. Bayramli has been actively engaged in cross-regional projects that explore the nexus between diplomacy, public health, human rights, and peacebuilding initiatives.
Mr. Bayramli is multilingual, with fluency in Turkmani, Dari, English, German, and Turkish. His scholarly contributions, in addition to numerous articles and papers, include authorship of the Turkish-language monograph “From Balkh to Bonn” and the forthcoming English-language volume “Which Afghanistan?” (scheduled for publication in February 2026).