A Long Way to Go for Public Healthcare

Zabiullah, 40, is suffering from asthma, but his two-week stay in the government-run Jamhuriat hospital has provided no relief.



“Look at that,” he said, pointing to a peeling, water-stained ceiling. “It leaks when it rains. We have to move our beds around all night to keep from getting wet.”



He also complained about the wood heater next to his bed, which keeps the eight-bed room warm but also fills the ward with smoke – not the best thing for an asthmatic.



“I am worse now than when I came in,” he wheezed.



Mohammad Qasem Sahibi, a doctor at the Jumhuriat hospital, admitted that conditions are far from ideal.



“I have nothing to examine a patient with except a stethoscope,” he said. And even that can be problematic, with eight doctors having to share one instrument.



Meanwhile, Nooria, 45, who suffers from heart disease, was being treated at the Blossom Health Care Centre, a private hospital located in the 4th district of Kabul.



Lying in a clean bed in a white-painted room, Nooria told IWPR, “I was first admitted to a government hospital for 20 days. I finally left and came here because there was no proper equipment, and the doctors weren’t giving me good care.”



Now Nooria says her health is much improved. She’s happy with the treatment she received from staff here. There are 20 doctors, including three foreigners who act in a supervisory role. Three of the doctors are women.



“I don’t care that they take money here,” said Nooria. “They provide good treatment.”



The right to free healthcare is enshrined in the country’s constitution. Yet, if they can afford it, many Afghans would rather go to a private medical facility than to the government’s underequipped, understaffed, and underfunded institutions.



Most people, however, don’t have that option as the fees charged by private hospitals, while modest by Western standards, put them beyond their reach.



Zahra, 40, came to the Afghan Private Hospital in the Khair Khana district of Kabul for an operation. “I had a goitre. The doctors removed it but charged me 200 US dollars,” she said. “I stayed two nights, and they charged me 24 dollars a night for the room, and another 24 dollars a night for my husband who’d come to help me. This is too much money for us.”



Hospital director Dr Azizullah Amin defends the fees they charge, “We have to buy all our own medical equipment, we have to pay the staff and pay the rent on the building. Of course we have to charge money.”



Dr Amin’s hospital has 40 medical personnel, both men and women. Doctors are paid between 200 and 700 dollars a month.



He said the hospital charges 10 dollars a night for a room, rather than the 24 dollars Zahra claimed.



Abdullah Fahim, an adviser to the health ministry, acknowledged that government-run hospitals suffer from many problems, but he also argued that because they provide free care, the public fails to value their services.



“People think that government doctors don’t know anything because they don’t have to pay them,” he said. “Payment for services is a good thing, even if it’s only a little. And we can use the money to pay staff and buy equipment.”



Fahim thinks it’s a mistake to make free healthcare a constitutional right. “I have asked parliament to revoke that clause in the constitution,” he said.



One state-run hospital in the northern city of Mazar-e-Sharif has already begun experimenting with charging for services. The prices are very low – just 40 cents for a night’s stay - and the money collected is being used to upgrade services.

Dr Mirwais Ravi, head of the public health department in Balkh province, says the experiment has been a success. “The public health ministry is completely satisfied,” he said.



Fahim said the health ministry has an annual budget of 25 million dollars. In addition, international donors have contributed an additional 33 million dollars over the past four years. But this is not enough, he says. “We have had to repair all the hospitals that were damaged during the wars. The money we receive does not meet all of our needs.”



There are 4,854 government-run hospitals and clinics in Afghanistan, compared with 65 private institutions.



Fahim is in favour of the existence of private hospitals but cautions that they have to adhere to guidelines set by the ministry.



“We have received complaints that patients are being charged huge amounts of money in private hospitals,” he said. “We will take immediate steps in this regard. We have already issued sanctions against several private clinics.”



State hospitals cannot compete with private institutions on salary, and this contributes to the problem. “Salaries in government hospitals are only 40 to 100 dollars a month,” said Fahim, adding that the government is trying to raise wage levels as part of general administrative reform of the health ministry.



It’s clear that most government-run hospitals have a long way to go before they can match the private facilities.



At Maiwand, one of the oldest hospitals, the child nutrition ward receives assistance from an international relief agency and is a model of cleanliness and efficiency. But it stands in stark contrast to the rest of the hospital.



Ziba, 28, sits next to her five-year-old son, Hamid, in the general children’s ward.



“Look at this,” she said angrily, pointing to her son’s mattress, sheet, and pillow. “It’s filthy and it smells terrible. Even a healthy person would get sick in here. Is this a hospital or a lunatic asylum?”



Hamid has been in the hospital for three days. He has bronchitis but no one has yet examined him, said his mother.



“When I ask the doctors they say ‘go away, we will come later’, but they never do,” she said, weeping. “I wish I had money so that I could take my son to a private hospital.”



Dr Mahmoud Gul Kohdamani, head of the Maiwand hospital, denied that his staff were providing substandard care. He echoed Fahim’s sentiments that the problem was one of perception, “Since treatment is free, people think that the quality of care is low. If the treatment was not free and the doctors got good salaries, all these problems would be solved.”



Mohammad Yama Noorzad, an orthopedist at the Wazir Akbar Khan government hospital, said low salaries explained the lack of interest and attention shown by doctors.



“Doctors prefer to work in private hospitals where they can make more money,” he said.



“If the situation continues unchanged, there will be no doctors at all in the government hospitals in the future.”



Salima Ghafari is an IWPR staff reporter in Kabul.