Bridging the healthcare gap in Afghanistan: A primer on India’s role

Reeling under years of poverty^[a]^[1] and war, Afghanistan’s healthcare system is deteriorating and is often considered one of the world’s most “inferior.”^[2] Basic amenities and infrastructure are absent, indicating poor quality of life. Indeed, Afghanistan is grouped in the “low human development category” and ranked 170 out of 189 countries in the 2019 Human Development Index (HDI)^[b]^[3] of the United Nations Development Programme (UNDP).^[4]

In the post-Taliban era, efforts have been made by the Government of Afghanistan to rebuild the healthcare system, mostly with the help of foreign aid owing to the country’s struggling economy and lack of technological know-how. A 2019 study by the World Health Organization (WHO) found that of the four percent of the national budget allotted to the Afghan Ministry of Public Health (MoPH), 80 percent is funded by foreign donors.^[5] Such dependence is likely to continue, as the MoPH has declared that it will depend “on the donor community for effective mobilization of funding necessary to realise the policy priorities of its National Health Strategy of 2016–2020.”^[6]

India has been one of the primary donors of reconstruction aid to Afghanistan, ever since the fall of the Taliban regime in 2001.^[c]^[7] Since then, it has helped rebuild hospitals, provided medicines, and conducted trainings for Afghan doctors.^[8] So far, however, India’s direct involvement in Afghanistan’s health sector has remained limited. In August 2019, the Afghan government announced its plan to expand the provision of quality healthcare. In response, three Indian health organisations signed contracts worth US$6.5 million with an Afghan health company under the country’s MoPH.^[9]

However, in light of the peace agreement signed between the US and the Taliban in February 2020,^[10] Afghanistan may be on the verge of major shifts. There are apprehensions about the Taliban’s return on the development scenario, particularly in the health sector, on which the Taliban holds restrictive views.^[d]Moreover, depending on the Taliban’s relationship with donor countries, the flow of foreign aid may be adversely affected, since most countries (including India) have never recognised the Taliban regime of 1996–2001 as a legitimate authority.

This brief has four objectives: to understand Afghanistan’s need for foreign assistance in building its healthcare system; examine India’s contribution in developing the system; identify improvements in Afghanistan’s healthcare compared to the Taliban era; and analyse the scope for India’s continued involvement in Afghanistan in the event of the Taliban’s return to power and its possible impacts on the health sector.

Reliable data on healthcare in Afghanistan is limited and difficult to obtain.^[11]Therefore, the figures included in this brief have been formulated based on World Bank Data. Further, owing to linguistic limitations, only English-language sources have been used.

By the time the Taliban era began in Afghanistan in 1996,^[12] almost 18 years of intermittent warfare had devastated the infrastructure and economy of the country.^[e]^[13] Only a fragment of the national budget was being allocated for healthcare, and the system remained ill-equipped and under-staffed.^[14]However, the Taliban’s rule, which was fundamentalist in nature and prohibitive in approach,^[f]^[15] sounded the death knell for the health sector. The inadequacy of healthcare facilities was exacerbated, as women were denied access to such amenities^[16] and female health practitioners were not allowed to work.^[17] As outdated notions of “modesty” took precedence over medical intervention, maternal mortality soared.^[18] Only one-third of Afghanistan’s districts had a maternal or child health clinic,^[19] and over 90 percent of all births took place at home. With poor maternal health, children suffered from birth defects, malnutrition and preventable diseases.^[20]

Across the country, treatments were repressed, and the overall health of the people began to decline. This was compounded by injuries from landmines, insurgencies-related violence, and punishments meted out for “disobedience” to the Taliban.^[21] Under this regime, there was no specific public-health policy or strategy, and a patent dearth of health infrastructure. Since most countries refused to recognise the Taliban regime,^[g] foreign assistance was unavailable to develop the health sector.^[22] Consequently, there was a brain drain of professionals,^[23] most NGOs withdrew,^[h]^[24] and there was a sudden shortage of healthcare professionals in Afghanistan.^[25] In a 1997 study conducted by WHO^[26] to measure how efficiency in health systems translated expenditure into health, Afghanistan was ranked 150 out of 191 countries on health and 173 out of 191 countries in the overall performance of healthcare systems.^[i]^[27] By 2003, two years after the Taliban regime had collapsed, Afghanistan had only 11 physicians and 18 nurses per 100,000 people; in 2004, there was one medical facility for every 27,000 people while some centres were responsible for as many as 300,000 people.^[28]

India’s longstanding ties with Afghanistan collapsed under the Taliban regime for several reasons, primary of which was India’s rejection of the Taliban ideology, the 1999 hijack of the Indian Airlines Flight 814,^[29] and the destruction of the Bamiyan Buddhas in 2001.^[30] Before the Taliban era, India had been an active developmental partner of Afghanistan; in 1966, India built a children’s hospital—the only one of its kind at the time of construction—which was later named Indira Gandhi Hospital for Child Health (IGHCH).^[31]

In 2001, after the fall of the Taliban regime, the transitional government of Afghanistan ushered in an era of reconstruction. India began renewing its engagements,^[32] since Afghanistan had the potential to act as its land bridge to Central Asia. A stable Afghanistan was also required to reduce the dangers of extremist violence, especially as India’s ties with Pakistan remained acrimonious.^[33]

Within the purview of healthcare, India signed the “Agreement on Cooperation in the Field of Healthcare and Medical Sciences” with the Islamic Republic of Afghanistan in 2005, wherein both countries would cooperate on eight sectors: Family Welfare; Public Health and Nutrition; Communicable Diseases; Medical Research; Indigenous System of Medicine; Medical Equipment and Pharmaceutical Products; Hospital Management; and Nursing and Midwifery. Article 3 of the Agreement categorised five ways in which such cooperation would be carried out:^[34] These included exchange of information in the field of health and medicine; exchange of health and medical experts; training in the mutually agreed identified areas; deputation of experts to attend international meetings organised in either country; and conducting symposia, academic meetings and working meetings

Since India served as a developmental partner to Afghanistan,^[35] not a donor country, no conditionalities were attached to the aid. Rather it was need-based,^[36] focused on addressing the priority areas identified in the Afghanistan National Development Strategy.^[37] The priority areas sought to remediate many of the wrongs of the Taliban era, leading to India’s aid being directed to these concerns, which included the health sector. While India’s involvement in the Afghan health sector has been limited compared to its engagement in other areas of development (See Figure 1), being demand-driven, the initiatives contributed significantly towards developing the country’s healthcare system.

India’s Direct Initiatives in the Afghan Health Sector

In 2001, based on the demand for urgent medical needs, India dispatched a team of 13 doctors and paramedics to Kabul. In 2002, camps were set up in several places for fitting artificial limbs for amputees victimised by landmines. A year later, Indian Medical Missions were set up in Kabul, Herat, Jalalabad, Kandahar and Mazar-e-Sharif, which continue to cater to nearly 30,000 patients every month.^[38] At the height of Taliban insurgency in 2008, India once again sent teams of doctors and paramedics to the vulnerable provinces of Herat, Mazare-Sharif, Shibergan and Kandahar.^[39]

One of the most crucial problems during the Taliban regime had been the rising child and maternal mortality rates. India contributed significantly to address this concern by reopening the IGHCH in 2003, which had been closed in 1992 due to the war. Further, India added to the IGHCH a three-storey surgical block, followed by the polyclinic block in 2007, and later equipped the diagnostic block with modern facilities. India also set up neo-natal and maternity care units.^[40] At present, the IGHCH is the largest paediatric hospital in Afghanistan and treats over 300,000 children annually.^[41]

In addition to undertaking major infrastructural developments, under the Small Development Project Scheme Phase I and II (US$20 million) and Phase III (US$10 million) India committed to undertake more than 200 projects, covering public health, education and community infrastructure.^[42] It has built basic health clinics in several border provinces.^[43] In 2008, India provided the Afghan MoPH with 10 ambulances, two each for use in Kabul and the regional hospitals in Jalalabad, Kandahar, Herat and Mazar-e-Sharif.^[44] In January 2019, the two countries signed 11 Memorandums of Understanding (MoUs), worth US$9.5 million, for infrastructure and public services such as health clinics. These projects are part of the 577 development projects funded by India, slated for 2005–21 and worth US$120 million.^[45]

Further, India conducts trainings of the IGHCH doctors and paramedics at the All India Institute of Medical Sciences in New Delhi. The IGHCH and the Malalai Hospital in Kabul have also been linked with reputed Indian hospitals through the SAARC (South Asian Association for Regional Cooperation) Telemedicine Project.^[46] Many Afghan doctors have received fellowships at the Sir Ganga Ram Institute of Post Graduate Medical Education and Research in Delhi, in different specialities such as cardiac, cosmetic and reconstruction surgery; chest medicine; and liver transplant.^[47] Additionally, India has promoted business for the Afghan health sector, with seven Afghan pharmaceutical distributors attending the 2014 Indian Pharmaceuticals and Healthcare Expo held in Mumbai. In 2015, a major Indian healthcare exhibition was held Kabul.^[48]

Afghanistan suffers from an acute shortage of quality medicines, and annually imports foreign drugs worth around US$300 million, from Pakistan, Iran, India, Turkey and Bangladesh.^[49] Since Afghanistan considers Indian pharmaceuticals and healthcare systems to be highly trustworthy,^[50] India provides free medicines, consultations and funds to the Afghan Red Crescent Society (ARCS) Programme.^[51] Part of the funds donated to the ARCS has been channelled to treating children suffering from congenital heart diseases.^[52] India is also a major contributor to the Afghanistan Reconstruction Trust Fund, which along with the World Bank, supports the System Enhancement for Health Action in Transition Program (SEHAT) of the Afghan Ministry of Public Health.^[53]

India’s Indirect Enterprises That Benefit the Afghan Health Sector

While only around two percent of India’s reconstruction aid to Afghanistan has been utilised specifically for the health sector, India has contributed significantly in this domain through indirect initiatives.

To improve child nutrition, in 2007, India participated in the School Feeding Programme and made provisions for almost one million school children to receive high-protein biscuits daily, through the World Food Programme.^[54] It also expedited the supply of wheat to Afghanistan, as part of the 1.1 million MT wheat donation commitments.^[55] Other indirect measures that India has undertaken include improving connectivity lines and promoting sanitation, which contribute to the development of the health sector, e.g. the Salma Dam Project, the Sahtoot Dam Project, the drinking water project,^[56] and the electricity transmission lines from Pul-e-Khumri to Kabul. Further, India has helped in upgrading the telephone lines in several provinces; dug tube-wells in others; and established toilet and sanitation complexes in Kabul.^[57]

Over the years, India has also become a favoured destination for medical tourism amongst Afghan citizens, due to the cost-effective facilities, availability of specialist doctors and easy connectivity. Of the thousands of Afghans who visit India every month, 70 percent are medical tourists.^[58] In 2017, India liberalised its visa regime to promote medical tourism. The validity of a tourist visa has now been increased to one year, and it allows a continuous stay of 90 days during each visit as against the previous provision of 30 days. The requirement for a gap of 60 days between two tourism visits, however, remains unchanged.^[59] To facilitate medical tourism further, India has made provisions for guidance to Afghan medical tourists, initiated measures to eradicate fraud by Afghan interpreters acting as touts for various hospitals/doctors, and invited companies promoting medical tourism in trade fairs/exhibition in Kabul.^[60] Interpreters have also been recruited to help the patients communicate with the hospital staff.^[61] For the ongoing treatment of children at Artemis, Max and Fortis Hospitals (New Delhi), India has given financial assistance to the ARCS.^[62] The significant influx of Afghan medical tourists in Lajpat Nagar in New Delhi, has made it the epicentre of Afghan life in India. The area also has pharmacies, travel agents, barbershops and moneychangers, all advertising in Afghanistan’s lingua franca, Dari;^[63] the neighbourhood is often called “Little Afghanistan.”^[64]

Recently, three Indian health organisations signed contracts worth an estimated US$6.5 million with an Afghan health company, with the aim of establishing a fully equipped diagnostic centre, an advanced dialysis centre, and a manufacturing plant for the production of pharmaceuticals in Kabul.^[65]

The Indian aid programme has been referred to as the “most focused and effective” assistance programme in Afghanistan.^[66] Afghanistan is a prime example of India’s aid and assistance programs,^[67] and such initiatives have contributed towards improvements in the Afghan healthcare systems as well as in the health of Afghans in the post-Taliban era.

From around 500 health facilities across Afghanistan in 2003, the number increased to more than 2,500 in 2018.^[68] Currently, there are more than 23,000 volunteer health workers and 41,500 health professionals assisting the MoPH throughout the country.^[69] There has also been an increase in the number of female doctors, which in turn has significantly improved antenatal care, post-natal care and immunisation levels.^[70] Consequently, maternal mortality, infant mortality and the under-five mortality rates have dropped significantly since 1996 (See Figures 2, 3 and 4).

These graphs indicate that there has been a steady decline in the mortality rates for all three categories. Treating 1996 as the base year (i.e. the year that the Taliban took over Afghanistan), the maternal mortality rate dropped from 1,240 per 100,000 live births that year to 396 per 100,000 live births in 2015, or a drop of 32 percent (See Figure 2) over 19 years. Infant mortality rate fell from 99.5 per 1,000 live births in 1996 to 51.5 per 1,000 live births in 2017, or a drop of 52 percent (see Figure 3) over 21 years. The under-five mortality rate declined from 143.5 per 1,000 live births in 1996 to 67.9 per 1,000 live births in 2017, or a drop of 47.3 percent (see Figure 4) over 21 years. Thus, the period of reconstruction brought about substantial improvements in infant mortality rate, closely followed by the under-five mortality rate.

Despite such progress, there remains an overwhelming scope for improvement, which will require foreign aid. However, recurring attacks by the insurgent groups threaten the security of donors and sabotage their efforts. In 2019 alone, the Taliban militants shut down 42 health facilities in the central province of Maidan Wardak^[71] attacked hospitals^[72] and held patients as hostages as a ‘bargaining chip’ against the counter-insurgency forces.^[73] Indian consulates in Jalalabad have also sustained grenade attacks,^[74] and the Indian Embassy in Afghanistan has been attacked twice.^[75]

Interestingly, however, in some sections within the Taliban, a more positive attitude towards healthcare has emerged as a result of exposure to a broader field of ideas, the humiliation of defeat, and the consequent need to make themselves more acceptable to the Afghan citizens.^[76] In the areas they dominate, the Taliban has created a parallel system of governance, through governing commissions responsible for administrative affairs including health. Currently, healthcare in Taliban areas is a hybrid of NGO- and state-provided services. The Taliban monitors clinics, checks staff attendance, and inspects equipment and medicine stocks. It has also been pressuring NGOs to expand healthcare access in rural areas and improve the quality of services. In a 2010 interview with the Outlook magazine, the Taliban stated that it understood India’s role in Afghanistan to be different from those of other countries, since India had never sent in troops to occupy it. It believed that if it ever returned to power in Afghanistan, it was possible for the country to maintain relations with India.^[77]Ten years later, the possibility of the Taliban’s return is imminent, with the peace agreement being signed between the US and Taliban on 29 February 2020.

The ground realities in Afghanistan are changing, leaving India’s position of dissociation from the Taliban untenable.^[78] The Taliban, too, is no longer averse to collaborating with India. There have been reports that it is seeking a possible dialogue with India, with its leaders stating that “like other countries, India too can be a dialogue partner.”^[79] However, the Taliban’s commitment to peace and negotiations must stand the test of time.

The US–Taliban Peace Agreement included a timeline of 14 months for all American and NATO troops to withdraw; a guarantee from the Taliban that Afghan soil will not be used to threaten US security; and negotiations with the Afghan government by 10 March 2020, which would lead to a permanent and comprehensive ceasefire.^[80] However, while the terms are idealistic on paper, the situation is different on the ground. Amidst disputes between the Taliban and Afghan government over the potential release of Taliban prisoners (an essential part of the peace deal) and continued Taliban violence, the scheduled date of 10 March for intra-Afghan talks has long passed and the negotiations are yet to be held.^[81] It is also important to remember that India had refused to recognise the Taliban regime in the 1990s and that its stance towards engaging with the resurgent Taliban is yet to be established. Thus, the future scenario may be any of the following broad alternatives with regard to India’s involvement in Afghanistan’s health sector.

Scenario 1

While it appears that the Taliban have moderated their ideologies to some extent, it is impossible to guarantee that this will continue in the years to come. Since the outcome of the intra-Afghan negotiations over power-sharing arrangements promised in the US–Taliban Agreement, is yet to be determined and uncertainty remains about the next elected head of the government,^[82] the Taliban could assume total control in Afghanistan. In such a scenario, at the helm of power and with no foreign troops stationed on Afghan soil, the Taliban may revert to their fundamentalist beliefs.

Consequently, Afghanistan’s relations with other countries will likely deteriorate and foreign aid could be curtailed. The healthcare system will suffer directly as a result. Under such a totalitarian regime, India’s developmental aid to Afghanistan could suffer a setback, adversely impacting the health sector. The IGHCH in Kabul had once been closed due to insurgencies. The growing partnership between Indian health organisations and Afghan health sectors, which is integral for the development of private-sector healthcare in Afghanistan, could also collapse. Medical tourism to India will be severely compromised, and the liaisons between Afghan and Indian hospitals for the training of doctors will eventually cease.

Scenario 2

If the intra-Afghan negotiations are delayed indefinitely, there could be continued uncertainty regarding the power-sharing arrangement between the Taliban and other governmental stakeholders. In such a situation, while foreign aid will likely continue to flow in predictably, insurgency attacks from the Taliban as well as counter-insurgency strikes could rise. This would hamper the donor countries’ ability to continue their reconstruction work. Moreover, with an increase in the number of attacks, healthcare facilities will be stretched beyond their capacity; in the long run, their functionality is likely to be affected. The problem of brain drain could also increase.

Afghanistan’s relationship with India might suffer under such circumstances, since the latter would rightly be apprehensive of the heightened violence, leading it to withdraw its staff from Afghanistan. While the healthcare infrastructure that India has built in Afghanistan could continue to serve, there is likely to be a serious shortage of Indian medical staff and supplies. Over time, this may also affect medical tourism to the country and the relations between Indian and Afghan healthcare centres.

Scenario 3

The third scenario is a middle path and is most favourable. If a power-sharing arrangement between the Afghan government and Taliban is reached, the resultant stability will be mutually beneficial for both Afghanistan and India.^[83]Only in this scenario will Afghan healthcare continue to develop. It is likely that India will agree to collaborate with the Taliban, and the developmental partnership between the two countries will remain intact. Further, an increase in the engagement of the private sector of both countries may, in time, boost India’s involvement in the Afghan health sector. With such services, Afghan citizens will have increased access to secondary and tertiary healthcare. Medical partnership between the two countries is also likely to increase, especially in the areas of medical training, business for pharmaceutical companies, and creation of new healthcare infrastructure. Thus, the solution lies in a compromise, wherein the healthcare sector is treated as a priority.

(The author would like to acknowledge Dr. Anasua Basu Ray Chaudhury, Senior Fellow, ORF, Kolkata for her constant guidance and Roshan Saha, Research Assistant, ORF, Kolkata for his unconditional help.)

^[a]As of 2017–18, 55.9 percent of the Afghan population live in poverty.

^[b]The Human Development Index is a summary measure for estimating the long-term progress in three basic dimensions of human development: a long and healthy life, access to knowledge, and a basic standard of living.

^[c] India was the fifth-largest bilateral donor to Afghanistan in 2012, and the largest amongst the regional countries in 2015.

^[d] There are apprehensions about the return of the Taliban because the health of women and children in Afghanistan had degenerated significantly during its regime (1996–2001) due to the group’s repressive principles, which are discussed later in this brief.

^[e]Before the Taliban takeover, Afghanistan had suffered the Saur Revolution in 1978, the Soviet–Afghan War in 1979–89, and Afghan Civil War between the Government of Afghanistan and the Mujahideens in 1989–96.

^[f] The Taliban followed an extreme brand of “deobandism” and, in some cases, were also inspired by Wahabism or Salafism, which sought to revive ancient Islamic values and impose Sharia law.

^[g] Only the United Arab Emirates, Saudi Arabia and Pakistan had recognised the Taliban rule in Afghanistan.

^[h] While NGOs trained health workers in Afghanistan, some international health workers from international NGOs, e.g. Doctors Without Borders, also worked in the areas not dominated by the Taliban.

^[i] The performance on the health level is measured as the ratio between achieved levels of health and the levels of health that could be achieved by the most efficient health system. The overall performance of the health system was measured using a similar process, by comparing achievement to expenditure.

^[1] “Population in multidimensional poverty, headcount (%)”, Afghanistan Profile, Human Development Reports, United Nations Development Programme, 2019, http://hdr.undp.org/en/indicators/38606.

^[2]“Afghanistan’s healthcare system struggles to rebound,” Aljazeera, 10 August 2016, https://www.aljazeera.com/news/2016/08/afghanistan-health-care-system-struggles-rebound-160810104017464.html.

^[3] For more details on the Human Development Index, see “Briefing note for countries on the 2018 Statistical Update: Afghanistan,” Human Development Indices and Indicators: 2018 Statistical Update, United Nations Development Programme, 2018, 1, http://hdr.undp.org/sites/all/themes/hdr_theme/country-notes/AFG.pdf.

^[4] “2019 Human Development Index Ranking,” Human Development Reports, United Nations development Programme, 2019, http://hdr.undp.org/en/content/2019-human-development-index-ranking.

^[5] Karl Blanchet, Feroz Ferozuddin, Ahmad Jan J. Naeem, Farhad Farewar, Sayed Ataullah Saeedzai and Stephanie Simmonds, “Priority setting in a context of insecurity, epidemiological transition and low financial risk protection, Afghanistan,” World Health Organization Bulletin 97 (1 April 2019): 347–376, https://www.who.int/bulletin/volumes/97/5/18-218941/en/.

^[6] National Health Strategy 2016‒2020: Sustaining Progress and Building for Tomorrow and Beyond, Ministry of Public Health, Islamic Republic of Afghanistan, September 2016, 9, http://www.nationalplanningcycles.org/sites/default/files/planning_cycle_repository/afghanistan/afghanistan_mophstrategy2016-2020_final09september2016111201614508950553325325.pdf.

^[7] For more information on India’s aid to Afghanistan, see “India – Afghanistan Relations,” Ministry of External Affairs, Government of India, August 2012, https://www.mea.gov.in/Portal/ForeignRelation/afghanistan-aug-2012.pdf. Also see “India-Afghanistan Relations,” Embassy of India, Kabul, Afghanistan, 2015, https://eoi.gov.in/kabul/?0354?000.

^[8] Ibid.

^[9] “Indian Companies Invest In Afghanistan’s Healthcare,” Tolo News, 17 March 2019, https://tolonews.com/business/indian-companies-invest-afghanistan%E2%80%99s-healthcare

^[10] Agreement for Bringing Peace to Afghanistan between the Islamic Emirate of Afghanistan, which is not recognized by the United States as a state and is known as the Taliban and the United States of America, 29 February 2020, https://www.state.gov/wp-content/uploads/2020/02/Agreement-For-Bringing-Peace-to-Afghanistan-02.29.20.pdf.

^[11] Seth G. Jones, Lee H. Hilborne, C. Ross Anthony, Lois M. Davis, Federico Girosi, Cheryl Benard, Rachel M. Swanger, Anita Datar Garten and Anga Timilsina, Securing Health: Lessons from Nation-Building Missions, RAND Corporation, 2006, 189, https://www.jstor.org/stable/pdf/10.7249/mg321rc.15.pdf?refreqid=excelsior%3A311f8038b07b81abeea084dce6b7dd55.

^[12] Zachary Laub, “The Taliban in Afghanistan,” Council on Foreign Relations, 4 July 2014, https://www.cfr.org/backgrounder/taliban-afghanistan.

^[13] For more details on the history of war in Afghanistan, see “Afghanistan profile – Timeline,” BBC News, 9 September 2019, https://www.bbc.com/news/world-south-asia-12024253.

^[14] Lesley Strong, Abdul Wali and Egbert Sondorp, “Health Policy in Afghanistan: two years of rapid change,” London School of Hygiene and Tropical Medicine, 2005, 9, https://pdfs.semanticscholar.org/e081/f95d61ae0ebf75d5dd145c728520cc731d71.pdf.

^[15] For more details on “Deobandism,” see Ahmed Rashid, Taliban: Militant Islam, Oil and Fundamentalism in Central Asia [Second Edition] (New Haven and London: Yale University Press, 2010), 88. For more details on Wahabism and Salafism, see Sayed Hassan Akhlaq, “Taliban and Salafism: a historical and theological exploration,” Open Democracy, 1 December 2013, https://www.opendemocracy.net/en/taliban-and-salafism-historical-and-theological-exploration/.

^[16] A. Faiz, “Healthcare under the Taliban,” The Lancet, 1997, https://www.ncbi.nlm.nih.gov/pubmed/9130961.

^[17] Stephanie Dubitsky, “The Health Care Crisis Facing Women Under Taliban Rule in Afghanistan,” Human Rights Brief 6, no. 2, article 7 (1999): 1, https://digitalcommons.wcl.american.edu/cgi/viewcontent.cgi?article=1576&context=hrbrief.

^[18] Ali M. Latifi, “Years of war and poverty take toll on Afghanistan’s healthcare,” Aljazeera, 25 May 2019, https://www.aljazeera.com/news/2019/05/years-war-poverty-toll-afghanistan-healthcare-190525101842119.html.

^[19] “Afghanistan’s Health Crisis,” POV, 9 September 2002, http://archive.pov.org/afghanistanyear1380/afghanistans-health-crisis/.

^[20] Ibid.

^[21] A. Faiz, op. cit.

^[22] “Taliban,” Encyclopædia Britannica, 11 December 2019, https://www.britannica.com/topic/Taliban.

^[23] Seth G. Jones, Lee H. Hilborne, C. Ross Anthony, Lois M. Davis, Federico Girosi, Cheryl Benard, Rachel M. Swanger, Anita Datar Garten and Anga Timilsina, op. cit.

^[24] For more information on the role of NGOs in healthcare during the Taliban era of Afghanistan, see “Afghanistan: Civilians at Risk,” A panel discussion co-sponsored by Medicines Sans Frontieres and the 92nd St. Y, 20 October 2001, https://www.doctorswithoutborders.org/what-we-do/news-stories/research/afghanistan-civilians-risk.

^[25] John R. Acerra, Kara Iskyan, Zubair A. Qureshi and Rahul K. Sharma, “Rebuilding the health care system in Afghanistan: an overview of primary care and emergency services,” International Journal of Emergency Medicine 2, no. 2 (June 2009), https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2700223/.

^[26] The World Health Report 2000, World Health Organization, 2000, 202–203, https://www.who.int/whr/2000/en/whr00_en.pdf?ua=1.

^[27] Ibid., 150.

^[28] “Country Profile: Afghanistan,” Library of Congress, Federal Research Division, August 2008, https://www.loc.gov/rr/frd/cs/profiles/Afghanistan.pdf.

^[29] Prabhu Chawla, “IC 814 hijack: Tough negotiation begins as India is up against desperate terrorists and Talibans,” India Today, 10 January 2000, https://www.indiatoday.in/magazine/cover-story/story/20000110-ic-814-hijack-tough-negotiation-begins-as-india-is-up-against-desperate-terrorists-and-talibans-776909-2000-01-10.

^[30] “Outcry as Buddhas are destroyed,” BBC News, 12 March 2001, http://news.bbc.co.uk/2/hi/south_asia/1216110.stm.

^[31] Rani D. Mulle, “India in Afghanistan: Understanding Development Assistance by Emerging Donors to Conflict-Affected Countries” in Changing Landscape of Assistance to Conflict-Affected States: Emerging and Traditional Donors and Opportunities for Collaboration, ed. Agnieszka Paczynska, Policy Brief 10, Stimson, August 2017, https://www.stimson.org/sites/default/files/file-attachments/India%20in%20Afghanistan%20Understanding%20Development%20Assistance%20by%20Emerging%20Donors%20to%20Conflict-Affected%20Countries_0.pdf.

^[32] Partha Pratim Basu, “India and Post-Taliban Afghanistan: Stakes, Opportunities and Challenges,” India Quarterly: A Journal of International Affairs63, no.3 (1 July 2007): 91–92, https://doi.org/10.1177/097492840706300304.

^[33] Shanthie Mariet D’Souza, “India’s Aid to Afghanistan: Challenges and Prospects,” Strategic Analysis, 10 December 2007, 834, https://www.tandfonline.com/doi/abs/10.1080/09700160701662328.

^[34] Agreement on Cooperation in the Field of Health Care and Medical Sciences between the Republic of India and the Islamic Republic of Afghanistan, Embassy of India in Kabul, Afghanistan, 2005, https://eoi.gov.in/kabul/?pdf0643?000.

^[35] Partha Pratim Basu, op. cit., 92–93.

^[36] Shakti Sinha, “Rising Power and Peacebuilding: India’s role in Afghanistan,” in Rising Power and Peacebuilding: Breaking the Mold?, eds. Charles T. Call and Cedric de Coning (Palgrave Macmillan, 2017), 140, https://scholar.google.com/scholar?hl=en&as_sdt=0%2C5&q=Rising+Power+and+peace+building%3A+India%27s+role+in+AFGHANISTAN&btnG=.

^[37] India and Afghanistan: A Development Partnership, Ministry of External Affairs, Government of India, 8, https://mea.gov.in/Uploads/PublicationDocs/176_india-and-afghanistan-a-development-partnership.pdf.

^[38] Ibid., 14.

^[39] Jisha Krishnan, “India and China bridging the healthcare gap in Afghanistan,” Health Analytics Asia, 2 August 2019, https://www.ha-asia.com/how-are-india-and-china-bridging-the-healthcare-gap-in-afghanistan/.

^[40] India and Afghanistan: A Development Partnership, op. cit., 14.

^[41] Neelapu Shanti, “Development cooperation marks Afghan-India partnership,” The Economic Times, 3 September 2018, https://economictimes.indiatimes.com/blogs/et-commentary/development-coop-marks-afghan-india-partnership/.

^[42] “India-Afghanistan Relations,” op. cit.

^[43] India and Afghanistan: A Development Partnership, op. cit., 28–29.

^[44] Nandita Palrecha and Monish Tourangbam, “India’s Development Aid to Afghanistan: Does Afghanistan Need What India Gives?” The Diplomat, 24 November 2018, https://thediplomat.com/2018/11/indias-development-aid-to-afghanistan-does-afghanistan-need-what-india-gives/.

^[45] Dipanjan Roy Chaudhury, “India signs 11 MoUs worth 9.5 million with Afghanistan,” The Economic Times, 21 January 2019, https://economictimes.indiatimes.com/news/defence/india-signs-11-mous-worth-9-5-million-with-afghanistan/articleshow/67617756.cms?from=mdr.

^[46] India and Afghanistan: A Development Partnership, op. cit., 14.

^[47] Jisha Krishnan, op. cit.

^[48] “India-Afghanistan Relations,” op. cit.

^[49] Shadi Khan Saif, “Afghan ministry takes step against counterfeit medicine,” AA, 29 0ctober 2017, https://www.aa.com.tr/en/asia-pacific/afghan-ministry-takes-step-against-counterfeit-medicine/951043.

^[50] “India-Afghanistan Relations,” op. cit.

^[51] Krzysztof Iwanek, “36 Things India Has Done for Afghanistan,” The Diplomat, 8 January 2019, https://thediplomat.com/2019/01/36-things-india-has-done-for-afghanistan/.

^[52] Shakti Sinha, op. cit.

^[53] Afghans First: India at Work in Afghanistan, Ministry of External Affairs, Government of India, 1, http://www.mea.gov.in/Uploads/PublicationDocs/189_Afghanistan-First.pdf.

^[54] Shanthie Mariet D’Souza, op. cit., 834.

^[55] “India-Afghanistan Relations,” op. cit.

^[56] Neelapu Shanti, op. cit.

^[57] Krzysztof Iwanek, op. cit.

^[58] Waslat Hasrat-Nazimi, “Afghans turn to India’s hospitals for treatment,” DW, 29 November 2013, https://www.dw.com/en/afghans-turn-to-indias-hospitals-for-treatment/a-17260216.

^[59] “India further liberalises visa policy for Afghan nationals,” The Economic Times, 3 February 2017, https://economictimes.indiatimes.com/news/politics-and-nation/india-further-liberalises-visa-policy-for-afghan-nationals/articleshow/56959978.cms?from=mdr.

^[60] “India-Afghanistan Relations,” op. cit.

^[61] Bhairvi Tandon, “India’s soft power advantage in the great game of Afghanistan,” Expert Speak, Observer Research Foundation, 1 July 2019, https://www.orfonline.org/expert-speak/indias-soft-power-advantage-in-the-great-game-of-afghanistan-52624/.

^[62] Shakti Sinha, op. cit.

^[63] “India a Hub for Patients From Afghanistan,” Refugees in the Media, 1 November 2013, https://www.unhcr.org.in/index.php?option=com_news&view=detail&id=30&Itemid=117.

^[64] Joe Harkins, “Afghan Medical Tourism Patients Find Welcome Mats in India,” Medical Tourism Magazine, 2014, https://www.medicaltourismmag.com/article/afghan-medical-tourism-patients-find-welcome-mats-india.

^[65] “Indian Companies Invest In Afghanistan’s Healthcare,” Tolo News, 17 March 2019, https://tolonews.com/business/indian-companies-invest-afghanistan%E2%80%99s-healthcare.

^[66] Ajay Shukla, “India Does Not Need Boots on Afghan Ground,” The New York Times, 22 September 2017, https://www.nytimes.com/2017/09/22/opinion/india-afghanistan-pakistan.html.

^[67] Nandita Palrecha and Monish Tourangbam, op. cit.

^[68] “How has Afghanistan achieved better health for its citizens?” World Bank Afghanistan, 5 April 2018, https://blogs.worldbank.org/endpovertyinsouthasia/how-has-afghanistan-achieved-better-health-its-citizens.

^[69] “Afghanistan Builds Capacity to Meet Healthcare Challenges,” World Bank, 22 December 2015, https://www.worldbank.org/en/news/feature/2015/12/22/afghanistan-builds-capacity-meet-healthcare-challenges.

^[70] “How has Afghanistan achieved better health for its citizens?” World Bank Blogs, 5 April 2018, https://blogs.worldbank.org/endpovertyinsouthasia/how-has-afghanistan-achieved-better-health-its-citizens.

^[71] “Obstructing health services,” Afghanistan Times, 18 July 2019, http://www.afghanistantimes.af/editorial-obstructing-health-services/.

^[72] “Afghanistan hospital attack death toll soars to 39,” Aljazeera, 20 September 2019, https://www.aljazeera.com/news/2019/09/killed-car-bomb-attack-afghan-province-zabul-190919042138106.html.

^[73] Sharifullah Sharfat and Ron Synovitz “Taliban Targets Medical Clinics In New Afghan Insurgency Strategy,” Radio Free Europe Radio Liberty, 27 September 2017, https://www.rferl.org/a/afghanistan-taliban-targets-hospitals-strategy/28760791.html.

^[74] Partha Pratim Basu, op. cit., 109.

^[75] Shanthie D’Souza, “India, Afghanistan and the ‘End Game’?” ISAS Working Paper No. 124, National University of Singapore, 23 September 2012, 12 https://papers.ssrn.com/sol3/papers.cfm?abstract_id=2150711.

^[76] Ashley Jackson, “Life under the Taliban shadow government,” Report (Overseas Development Institute), June 2018, 10, https://www.odi.org/sites/odi.org.uk/files/resource-documents/12269.pdf.

^[77] Rahimullah Yusufzai, “The Taliban And India Can Be Reconciled: Taliban spokesman Zabihullah Mujahid spoke to Rahimullah Yusufzai,” Interview, Outlook, 5 April 2010, https://www.outlookindia.com/magazine/story/the-taliban-and-india-can-be-reconciled/264839.

^[78] Harsh V. Pant, “India’s dilemmas in Afghanistan,” Expert Speak, Observer Research Foundation, 2 August 2019, https://www.orfonline.org/research/indias-dilemmas-in-afghanistan-53378/.

^[79] Kallol Bhattacharjee, “Taliban hints at possible dialogue with India,” The Hindu, 26 August 2019, https://www.thehindu.com/news/national/taliban-hints-at-possible-dialogue-with-india/article29279015.ece.

^[80] “US-Taliban deal: Can peace finally come to Afghanistan?” Aljazeera, 7 March 2020, https://www.aljazeera.com/programmes/talktojazeera/2020/03/taliban-deal-peace-finally-afghanistan-200306070535568.html.

^[81] Afghanistan: Background and U.S., Policy In Brief, Congressional Research Service, 11 March 2020, Summary, https://fas.org/sgp/crs/row/R45122.pdf.

^[82] Pamela Constable, “Standoff between Afghan President Ghani and rival Abdullah threatens Taliban peace deal,” The Washington Post, 15 March 2020, https://www.washingtonpost.com/world/asia_pacific/standoff-between-afghan-president-ghani-and-rival-abdullah-threatens-peace-deal/2020/03/15/41d4e8e8-6657-11ea-8a8e-5c5336b32760_story.html.

^[83] Dawood Azami, “Afghanistan war: What could peace look like”? BBC World Service, 14 July 2019.

Issue BriefsPublished on May 24, 2023 PDF Download

Bridging the healthcare gap in Afghanistan: A primer on India’s role

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Bridging the healthcare gap in Afghanistan: A primer on India’s role

Issue BriefsPublished on May 24, 2023 PDF Download

Bridging the healthcare gap in Afghanistan: A primer on India’s role

India’s Direct Initiatives in the Afghan Health Sector

India’s Indirect Enterprises That Benefit the Afghan Health Sector

Scenario 1

Scenario 2

Scenario 3

Author

Sohini Bose

Indexing

Publications

Apr 18, 2024

International Affairs | Indian Ocean

Apr 18, 2024