By Rod Nordland
KABUL, Afghanistan — The patients in the four hospitals run by Doctors Without Borders in Afghanistan are the lucky ones, by all accounts, having arrived at well-stocked facilities that maintain international standards with high-quality free care.
But when Doctors Without Borders, a French medical aid organization also known as Médecins Sans Frontières, surveyed 800 of those patients last year, the results showed a dismaying picture of unmet health care needs.
Nearly one in five of the Afghan patients, 18.4 percent, had a close relative or friend who died last year because that person was unable to reach medical care — in some areas because of high costs, even though health care is supposed to be free in Afghanistan, and in other areas because the war posed an obstacle to getting to facilities.
“As troops pack their bags, M.S.F. sees a war that still rages in many parts of the country and a failure to meet people’s increasing medical and humanitarian needs,” the group said in a report released on Tuesday.
The report took issue with a widely quoted World Bank statistic that 85 percent of Afghans now have access to health care, compared with only 9 percent in 2001. If the patients at its hospitals reported such difficulties, the report reasoned, “Beyond M.S.F.’s reach, large numbers of people continue to suffer illness or injury without recourse to medical care.”
Jessica Barry, a spokeswoman for the International Committee of the Red Cross, which supports two hospitals in Afghanistan as well as 44 Red Crescent Society clinics, said her agency had also seen similar problems. “We see and believe there is very difficult access to health care,” she said. An International Committee of the Red Cross survey issued in 2009 found that 68 percent of Afghans did not feel they had access to adequate health care.
Of the Doctors Without Borders patients interviewed in Khost, in eastern Afghanistan, where the organization runs a maternity hospital, 26 percent said they knew a close relative or friend who had died for lack of access to health care. Even in Kabul, 13 percent of patients said they knew someone who had died, and in Helmand Province 16 percent said they did. In the past year, a third of those in Helmand, in the south, said that fighting had prevented people they knew from receiving medical treatment. In Kunduz, in northern Afghanistan, the percentage was 19.
“Most people think 2013 was one of the most violent years, if not the most violent year,” said Benoit De Gryse, the Doctors Without Borders country director here. Even more people have been in need of emergency medical services, and reaching them safely has become harder.
The report blamed both pro-government and antigovernment forces for impeding access to health care and criticized plans announced by the Afghan authorities to use many health clinics as polling places in the coming presidential election — making them targets of insurgents who have vowed to disrupt the vote.
“This puts patients and the staff working in these health centers at increased risk, ultimately making it dangerous for patients to receive the care they need,” it said.
The report also stated that many patients said they discovered that health care facilities they wanted to visit were unstaffed, unsupplied or, in some cases, closed or even nonexistent. In other cases, although public facilities were meant to be free, patients could not afford prices demanded of them for food and medicine.
A doctor reviewed the X-ray of a sick child in a hospital managed by the French aid organization Doctors Without Borders in Kabul, Afghanistan, on Tuesday. (Photo: Mauricio Lima/The New York Times)
“Official accounts of Afghanistan’s health system, however, habitually emphasize achievements while neglecting unmet medical humanitarian needs,” the report said.
Ahmad Zia Naiem, the deputy minister of health for Afghanistan, complained about the aid group’s report, saying it had not received permission from the ministry’s ethical review board before preparing the report. He also said a survey of 800 patients “cannot represent the entire sector in the country.”
Mr. De Gryse was particularly critical of efforts by the American military coalition and its network of Provincial Reconstruction Teams, run mostly by the United States but also by its allies, which built many rural health care facilities.
Most of the Provincial Reconstruction Teams were dismantled by last year, and many of the facilities and projects they funded soon disbanded. Because the teams were seen as part of the military mission, their efforts to hand over health care facilities to aid groups were largely spurned. “So now most of them are defunded, or have been closed,” Mr. De Gryse said. “That does not mean they have not treated a single patient, but they had no long-term vision.”
The report said that “by using aid as a military tool, donors have often failed to adequately prioritize help for the most vulnerable first, provide effective assistance or place beneficiaries’ interests over their own political and military ones.”
In many places in the country, Mr. De Gryse said, Doctors Without Borders workers have found shell facilities. Examples he cited included the Bost Hospital in the southern city of Lashkar Gah, which had a basement full of donated supplies when the organization took it over in 2009, but not a single doctor. Elsewhere they found donated ambulances with no way to fuel them, and donated high-tech equipment with no generators to run them and no one trained to operate them.
The survey of the group’s patients also provided glimpses of how widespread an effect war has had on families. Roughly a fourth of the surveyed patients had seen a family member or neighbor killed in the past year.
Jawad Sukhanyar contributed reporting.