Afghanistan : Women have a key role in the health system

Chantal Autotte-Bouchard is a public health and tropical medicine nurse. She has been involved in various humanitarian crisis contexts, notably in sub-Saharan Africa, Haiti and India, before joining Première Urgence Internationale as Health Advisor at the organisation’s headquarters. Back from a visit to Afghanistan, she shares her experience with us.

Chantal’s role is to support the field teams in the implementation of health programmes and to ensure their qualitative follow-up.

Although caring for undernourished children is no longer a secret for her, Afghanistan is a new context for Chantal. She has to grasp new cultural codes in a country that is entering a new political chapter with heavy consequences for the health system.

“I needed to understand how the teams are implementing health activities, with whom and how…following the national health system or focusing on other solutions. The way we think about our programmes is crucial: setting up a mobile clinic in Afghanistan is different compared to Nigeria, for example, which is a more familiar context for me.

A person’s well-being and drivers of good health are specific to each individual, a patient-centred approach will require several adjustments, and cultural factors play an important role when providing care to the person. It will often be necessary to act simultaneously on several aspects: primary health care, but also nutrition, access to water, etc.”

Dealing with the constraints of the field

Aide Médicale Internationale opened the mission in Afghanistan over 40 years ago before becoming Première Urgence Internationale. The teams have a long experience in conducting health programmes, particularly at the provincial level where the community approach is the basis for the implementation of activities. The purpose is to reach families living in the most remote areas so that they can benefit from access to health services.

“Distance is of course a major obstacle to accessing families, especially women and children. This problem can be found in the Congo where sometimes the health centres are very far from the patients’ homes. They can travel miles to get there and then return home because the centre is closed due to a lack of medicines for example, but it can also be for a thousand other reasons.”

In Afghanistan, distance is a major factor, but there are also cultural aspects: women no longer have the chance to go spontaneously to a centre if a «Mahram», a chaperone who is usually the patient’s spouse, son or even father, does not accompany them.

This is why it is important to understand the traditional codes to better analyse the medical solutions that have been provided by our teams. There are of course minimum standards of care, but the quality of the response must also take into account the constraints on the ground.”

Avoiding a two-tier system

On 15 August 2021, Afghanistan experienced a change of power. The international community immediately decided to suspend the bilateral aid that was largely financing the Afghan health system. There is no longer any question of granting funds to Afghan institutions to strengthen the country’s public policies; aid will henceforth be channelled essentially through the United Nations and humanitarian organisations, with new conditions.

However, the needs are still there and the challenge is all the more important as in 2023 two out of three people will depend on humanitarian aid to survive. Women and children represent 77% of the population and are the first to be affected by the deterioration of living conditions.[1]

“Some donors refuse to fund fixed health structures, so if we want to maintain access to health services for families, we must give priority to mobile medical units. This is what we have been doing for many years. The main coordination of the mission is in Kabul, while our offices located in Eastern and South-Eastern provinces organise the deployment of mobile units in different districts. We take into account the needs and we remain careful to not bypass the fixed health services that are able to run activities.

With the decision to stop supporting fixed structures, there is a risk of having a two-tier system. Mobile units may be very well equipped to provide first aid, while some centres or district hospitals will not have sufficient resources to properly manage patients during their care pathway. Our teams provide basic primary health services, and can prescribe treatments such as antibiotics in some cases, but it is true that if we want to guarantee quality care, the whole chain must be strengthened.”

Within our mobile units there is generally a doctor or a nurse, accompanied by a midwife, who will cover both the nutritional needs and the pre- and post-natal care of women.

The mobile units will also provide catch-up vaccination, particularly for children and babies, and are increasingly equipped with a mental health and care professional to create spaces for discussion with patients.

“Prevention remains one of our main challenges…

Where things get complicated is when we want to do community mobilisation for preventive activities or awareness raising on care practices. Women can only go to public places if their «Mahram» accompanies them, which does not facilitate access to them and limits an environment conducive to exchange. It is even less easy for them to meet in other homes with women who are not part of their close circle.

In Senegal, community groups are much more spontaneous. Here, the exchange of experience between women and mothers is less obvious. Raising awareness about simple things such as washing hands after changing a child or recommendations for avoiding cases of diarrhoea is sometimes difficult without the possibility of holding collective sessions. Women use to attend such workshops with their children as in many other contexts, while men stay away or wait outside.”

Women play an essential role in public health…

Chantal works closely with the Medical Coordinator of the mission. When they both go to a maternity hospital, a midwife accompanies them to show them a delivery room…

“The place was not very ergonomic and the delivery table was a bit cold. At this point, I tell myself that it’s my western nurse’s perspective that is conditioning me. I look around the room, which doesn’t offer much privacy, but I can see that the equipment is there. There is everything you need for a reasonably safe delivery. The midwife is happy to have equipment that she didn’t necessarily have before. I then realise my need to take a step back while keeping the basics of medical ethics around the well-being of the patient.

Getting this equipment in a context like Afghanistan becomes a feat. Another example illustrates this difficulty: Première Urgence Internationale took several months before it was able to send a shipment of medicines by air. The international sanctions imposed and the rules set by the new authorities must be taken into account. Once the shipment has been cleared through customs, the teams will finally be able to supply their units with these medicines to provide consultations.

For the midwife, continuing her work is in itself a challenge, yet she is central to the care of pregnant and breastfeeding women as well as infants and young children. Without female medical staff, the mobile units that are deployed in rural areas will no longer have access to women and girls, just as in the fixed units.

Without female staff, the entire health system is at risk.

Watch the animation on the place of women in Afghanistan

[1] OCHA