Emergency, critical and operative care in Afghanistan: pathways to overcoming fragmentation and strengthening access...

Emergency, critical and operative (ECO) services are essential pillars of a resilient healthcare system and are integral to achieving universal health coverage, especially in post-conflict low- and middle-income countries like Afghanistan. The objective of this study is to evaluate the capacity, safety and availability of ECO services, and to understand their integration relation with barriers, facilitators and system level factors contributing to the delay to receive ECO care in nine Afghan provinces.

This study used a concurrent mixed-methods approach with explanatory data analysis and interpretation. Quantitative data were obtained from adapted WHO Harmonized Health Facility Assessment and WHO Surgical Assessment Tool, complemented by qualitative interviews with hospital directors, surgeons and gynaecologists from 11 Ministry of Public Health-led facilities including maternal, district, provincial and regional hospitals across nine provinces. The dimensions of staff, supplies, infrastructure, safety protocols, training, and surgical and obstetric/gynaecological capacity were assessed. Interviews explored providers' perspectives on accessibility, referral systems, training and gendered barriers to care.

Data revealed significant gaps in workforce, safety, emergency protocols, anaesthesia staff, resuscitation equipment and diagnostic tools. No facility met the WHO benchmark for essential surgical services. The 11 interviews confirmed systemic fragmentation, lack of communication across facilities, informal referrals, frequent supply shortages and restricted access to care for women, exacerbated by social and cultural norms. Staff often worked without pay, and training was irregular.

Afghan ECO care is fragmented and staffing and structural limitations and socio-political factors contribute to fatal delays. Leveraging existing processes such as the non-governmental organisation networks-especially amid critical underfunding for international agencies-may offer pragmatic low-cost strategies to strengthen ECO services in the Afghan post-conflict context, while future work should focus on people-centred needs assessment.