trapped

TRAPPED Between Rhetoric And Reality

war poverty mortality rates politicised aid

AFGHANISTAN

CONFLICT

35 years of war

2001 US led intervention

2014 violence continues Surge in civilian deaths

Humanitarian needs grow

POVERTY and HEALTH

Women: x 100 more likely to die giving birthChildren: 1/10 die before five years

Underestimations

1/3 below poverty line

AID as AMMUNITION

Win ‘hearts and minds’

Threat based, not needs based

Selective Storytelling

Fails the most vulnerable

Blurred Boundaries

“Best Performing” Reconstruction Area

“Best thing the US did in Afghanistan”

Exuberant claims

Veil

Spin

OBJECTIVES

Clearer picture: access to healthcare Understand

barriers: Types ExtentImpact

METHODSStudy period: Jun – Oct ‘13

Cross-sectional survey: 800+ patients, caretakers

LOCATIONS

DATA COLLECTION

Questionnaires, 763 : structured, pre-tested

Individual interviews, 35: semi-structured Focus groups, 12: semi-structured

Additional information:- MSF medical reports - Key interlocutor interviews

✓ MoPH permission for survey

ETHICS

✓ Informed oral consent

✓ Confidentiality

✓ No identifiers

Formal review not sought

RESULTS Deadly combination of barriers

PreventDelay

VIOLENCE

1 in 4 people experienced violence

7 in 10

4 in 10

barrier to reach MSF

conflict as a barrier

n=763

DISTANCE

Taking wounded to Kunduz distance a major difficulty

Perilous Journeys 1 in 3

COSTS

2 in 3 Poor, extremely poor

$1 day

Medical costs previous illness $32

Household spending/week $54

Total cost previous illness $41 costs more than 1 month of income

1 illness episodePeople per household 11

forced to borrow money or sell goods

2 in 5 44%

to obtain healthcare during a recent illness.

HEALTH SYSTEM GAPS

Rise in Numbers

Too Few

4 in 5 Bypass

Proximity ≠

Access

✗ availability

✗ quality

StaffServicesTreatments

“empty, lacking medicines, qualified staff, and electricity, closed, long queues, corruption, malpractice, high prices, no

referral“

PARTIES TO THE CONFLICT

Active fighting

Occupying facilities

Deliberate delaysHarrassment

Attacks,medical vehicles,personnel 450 health facilities

close - insecurity

Sharp increase in military intrusion

“I can’t go to the government doctor in my area because of the insurgents and other problems. They don’t like us to go to clinics supported by the government. If I go there, maybe the insurgents will arrest me, ask me why I was there, what I was doing there.”- Male, 22 years, farmer, Nawzad district, Helmand

EFFECT

1 in 5

LACK OF ACCESSto medical care

Death

JOURNEY 36%COST 32%

CONFLICT 18%

DEATH REASONS FOR LACK OF ACCESS TO CARE

“In the last years violence has blocked us coming to health centres and hospitals more

than 100 times. The fighting doesn’t stop when there are

injured people. So we wait, and then they die, and the fighting continues.”

- Male, 25 years, school principal, from Baghlan province

LIMITATIONSHealth facility survey

Underestimate barriersUrban v rural bias

Responder bias

CONCLUSION

Far from asimple success story

Remarkable gap – paper and practice

Meaningful medical care not available

Serious, often deadly, risks

Neutral, needs basedPragmatic, principledReality, not rhetoric

Uphill struggle

THANKS

Benoit deGryse, Renzo Fricke, Catherine Van Overloop, Mit Philips, Tom DeCroo, Silvia PinedaCorinne Baker, Jehan Bseiso, Jonathan Whittall

Shahab

Ilham

Kamal

Thank you