1. TRAPPED Between Rhetoric And Reality

2. warpovertymortality rates politicised aid AFGHANISTAN

3. CONFLICT 35 years of war 2001 US led intervention 2014 violence continues Surge in civilian deaths Humanitarian needs grow

4. POVERTY and HEALTH Women: x 100 more likely to die giving birth Children: 1/10 die before five years Underestimations 1/3 below poverty line

5. AID as AMMUNITION Win ‘hearts and minds’ Threat based, not needs based Selective Storytelling Fails the most vulnerable Blurred Boundaries

6. “Best Performing” Reconstruction Area “Best thing the US did in Afghanistan” Exuberant claims

7. Veil Spin

8. OBJECTIVES Clearer picture: access to healthcare Understand barriers: Types Extent Impact

9. METHODS Study period: Jun – Oct ‘13 Cross-sectional survey: 800+ patients, caretakers

10. LOCATIONS

11. 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

12. ✓ MoPH permission for survey ETHICS ✓ Informed oral consent ✓ Confidentiality ✓ No identifiers Formal review not sought

13. RESULTS Deadly combination of barriers Prevent Delay

14. VIOLENCE 1 in 4 people experienced violence

15. 7 in 10 4 in 10 barrier to reach MSF conflict as a barrier n=763

16. DISTANCE Taking wounded to Kunduz  distance a major difficulty Perilous Journeys 1 in 3

17. COSTS 2 in 3 Poor, extremely poor $1 day

18. costs more than 1 month of income 1 illness episode 

19. forced to borrow money or sell goods 2 in 5 44% to obtain healthcare during a recent illness.

20. HEALTH SYSTEM GAPS Rise in Numbers Too Few

21. 4 in 5 Bypass Proximity ≠ Access

22. ✗ availability ✗ quality Staff Services Treatments “empty, lacking medicines, qualified staff, and electricity, closed, long queues, corruption, malpractice, high prices, no referral“

23. PARTIES TO THE CONFLICT Active fighting Occupying facilities Deliberate delays Harrassment Attacks, medical vehicles, personnel 450 health facilities close - insecurity Sharp increase in military intrusion

24. “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

25. EFFECT 1 in 5 LACK OF ACCESS to medical care Death

26. JOURNEY 36% COST 32% CONFLICT 18% DEATH REASONS FOR LACK OF ACCESS TO CARE

27. “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

28. LIMITATIONS Health facility survey Underestimate barriers Urban v rural bias Responder bias

29. CONCLUSION Far from a simple success story Remarkable gap – paper and practice Meaningful medical care not available Serious, often deadly, risks Neutral, needs based Pragmatic, principled Reality, not rhetoric

30. Uphill struggle

31. THANKS Benoit deGryse, Renzo Fricke, Catherine Van Overloop, Mit Philips, Tom DeCroo, Silvia Pineda Corinne Baker, Jehan Bseiso, Jonathan Whittall Shahab Ilham Kamal

32. Thank you