5. Medical Tourism
Medical ‘tourism’ – travelling to another country for cheaper or better healthcare – is a fast-growing industry globally. Poor healthcare facilities and the absence of certain technologies and expertise in Afghanistan have created an income stream for neighbouring countries as Afghan people cross their borders for medical treatments. Rivalry between India and Pakistan has now extended into competition to attract Afghan patients. Iran, too, is emphasizing its cultural similarities as a means of attracting more Afghan patients.54
Pakistan has generally been the most popular destination of Afghan medical tourists, at times accounting for around 90 per cent of treatment-seeking visits. This is despite higher costs – foreigners are charged more than Pakistanis – and the bureaucratic hurdles. Following the Soviet invasion in 1979, a large number of Afghans moved into the Hayatabad suburb of the Pakistani city of Peshawar. As the number of Afghans using medical facilities increased, two specialist hospitals – the Rehman Medical Institute, which opened in 2002, and the North West General Hospital, which opened in 2009 – were established in Hayatabad, at times admitting thousands of Afghans per month. Despite new medical facilities opening in Kabul and Jalalabad, Peshawar was more accessible for many Afghans. This was partly because of the 30-year history of Afghan migration to Peshawar, but also because shared linguistic ties made it easier for Afghans to navigate any complexities encountered in seeking medical services. While the porous nature of the Afghan–Pakistan border facilitated cross-border travel for the purposes of seeking medical treatment, few of these medical tourists possessed any paperwork, which left them liable to be stopped and questioned by police.
In April 2016 Pakistan tightened the visa requirements for Afghans entering the country, as a direct consequence of which the number of Afghans using medical services in Peshawar fell to around 50 per month.
In April 2016 Pakistan tightened the visa requirements for Afghans entering the country, as a direct consequence of which the number of Afghans using medical services in Peshawar fell to around 50 per month. This had negative implications not only in terms of individual Afghan citizens’ health issues, but also in terms of revenues for Pakistani service providers – the Peshawar specialist hospitals cited above and a number of private citizens who supply private transport services to Afghans seeking treatment in the Pakistani province of Khyber Pakhtunkhwa (of which Peshawar is the capital, and into which the border region known as the Federally Administered Tribal Areas was merged in 2018).
India, meanwhile, has long promoted itself as a destination for medical tourism, and the costs of treatment there are lower than in Pakistan. The total number of medical tourists visiting India rose from 130,000 in 2015 to 200,000 in 2016.55 However, these figures refer to patients entering India with a medical visa. Some reports suggest that the number of international patients was more than double this number.56 According to the Indian government, revenues from medical tourism are expected to triple from $3 billion in 2015 to $9 billion by 2020.57
From 2016 India sought to meet the medical needs of Afghans constrained from visiting Pakistan and introduced a same-day visa policy for Afghan medical tourists. As the number of Afghans using Pakistani hospitals fell, India became one of the main destinations for Afghans seeking treatment. In 2015/16 fewer than 30,000 Afghans were seeking medical treatment in India.58 Subsequently these numbers have risen significantly. In late 2018 it was reported that more than 500 Afghans sought an Indian visa from the Indian consulate in Herat every day. Of these, 80 per cent sought medical treatment.59
Although healthcare is cheaper, for many Afghans the cost of flying into India, along with the cost of accommodation, is prohibitive. In addition, the language barrier remains a challenge for many Afghans visiting India, although many hospitals do provide Dari/Pashto interpreters for patients from Afghanistan. (Both languages are widely spoken in Peshawar and throughout Khyber Pakhtunkhwa.) In late 2018 the newly appointed health minister for Khyber Pakhtunkhwa, Dr Hisham Inamullah Khan, suggested that the provincial government was proposing to offer incentives for Afghans to use the province’s hospitals, with treatment to be offered at district hospitals as well as at the major government-run hospitals in Peshawar. If these proposals are followed through, Pakistan may well revert to being the major destination for Afghan medical tourists.60
As well as Afghan medical tourists travelling to healthcare facilities in larger cities in neighbouring countries, there are opportunities for local-level cross-border medical tourism. This is particularly the case in northeastern Afghanistan, which is, to a significant extent, cut off from the rest of the country. Some parts of mountainous Badakhshan, for example, are up to 18 hours’ travel time from the provincial capital, Faizabad, in good weather. During the winter months, snow frequently blocks roads, making the journey impossible.
As with trade and energy, cross-border cooperation on healthcare between Afghanistan and Tajikistan has emerged as an extension of the ongoing development of the healthcare sector in southern Tajikistan. During the Soviet period, there had been significant investment in healthcare services in Tajikistan. However, the collapse of the Soviet Union meant that the provision of subsidies to poorer regions such as Tajikistan came to an end, a situation exacerbated by the 1992–97 civil war. In 1995 per capita spending on healthcare stood at just $28 (in purchasing power parity terms).61 Budgets for healthcare were hard hit, and health indicators such as maternal and infant mortality began to deteriorate. By 2000 UNICEF estimated that the infant mortality rate stood at 89.0 deaths per 1,000 live births, the worst in the former Soviet Union.62
Years of underinvestment affected the quality of physical infrastructure, such as hospitals and health centres. The government of Tajikistan launched a reform programme intended to create a sustainable and cost-effective system of healthcare, with universal access. By 2013 per capita spending had risen to almost $170.63 Its priorities included primary care, public health and improved efficiency. As well as investing in healthcare professionals, the reforms aimed to involve the community in healthcare provision. To this end, the government worked in tandem with the AKDN and its agency, Aga Khan Health Services (AKHS) in specific regions, including the GBAO, to rehabilitate the healthcare system.
Cross-border healthcare cooperation between the GBAO and the neighbouring Afghan province of Badakhshan has evolved from these developments. Large areas of Badakhshan have long lacked both medical facilities and trained staff. Patients who lived close to the Tajik border – and very close to the Tajik city of Khorog – were traditionally advised to travel to the provincial hospital at Faizabad, some 18 hours’ drive away. Many seriously ill patients would not survive the journey, and as a consequence the province had Afghanistan’s highest rates of maternal and infant mortality.
Thank God, for several years now we have not had to experience such pain any more due to the cross-border facility, which means we get Tajik surgeons … [if the facility ended] we will end up in the situation where our patients would lose their lives despite needing insignificant surgical procedures.
Interview with GP, Shughnan district, Badakhshan province, Afghanistan, August 2018
A cross-border health project was initiated in 2010 with the aim of improving the quality of healthcare in communities on both sides of the Afghanistan–Tajikistan border. Under the project, it has been possible to treat critically ill patients from Afghan Badakhshan in Tajik hospitals; for Tajik health professionals to provide healthcare services in Afghanistan; and for policymakers from both countries to undertake reciprocal cross-border study tours where they can observe healthcare systems in the partner country.
Under the joint healthcare programme, three comprehensive health centres (CHCs), with around 10 beds each, have been established on the Afghan side of the border; these are situated close to the bridges which cross the Pyanj river – and the international border – at Nusai, Ishkashim and Shughnan.
Afghan patients are assessed using three categories, and their treatment proceeds accordingly. If a patient cannot be treated by a CHC in Afghanistan, or is critically ill, they are categorized as ‘emergency’. By means of the programme, the CHC can request the transfer of that patient to an appropriate hospital in the GBAO. The joint healthcare agreement then enables the patient to be treated in the Tajik facility without the need for a visa, and the programme, thanks to its donor funding, covers the cost of their treatment.
Since Afghan CHCs lack the personnel and facilities to provide specialist services, the agreement also provides for Tajik doctors and specialists (such as dermatologists, ophthalmologists and surgeons) to cross into Afghanistan on a routine basis after requests from Afghan CHCs. Routine visits last three to five days, with the Afghan consulate in Khorog providing visas to the Tajik health professionals and specialists.
Thirdly, the programme enables Afghan CHCs to send clinical samples to Khorog hospitals for diagnostics and testing – facilities that do not exist in this part of Afghan Badakhshan. Special insulated containers are provided for depositing samples, with teams from both countries meeting each other at the nearest bridge (which also serves as the border crossing) to transfer boxes.
Since its inception, the programme has provided more than 3,000 consultations and 300 surgeries annually. AKDN has also provided dental care for Afghans, and has enabled Tajik trainers and specialists to provide training to Afghan healthcare professionals.
A Khorog-based hospital can respond to an emergency surgery request in under an hour, while it would take up to 10 hours to transfer the same patient to the nearest suitable surgical facility within Afghanistan. Structural issues within the Afghan system of healthcare governance further complicate this picture, and Afghans have for many years faced considerable difficulties in receiving basic healthcare as a result. For instance, a health facility in Shighnan district in Badakhshan province, which is a day’s drive from the provincial capital of Faizabad, is perceived as needing the same staffing structure (i.e. with no allocation of surgical staff) as a district in Kabul province, which may lie just a 30-minute drive away from Afghanistan’s capital city.
Over the past six years the project is widely viewed as having transformed healthcare in Badakhshan. Healthcare provision has improved as cross-border cooperation has progressed. Access to electricity has enabled Afghan healthcare facilities to provide a range of services that it was not previously feasible to offer, such as ultrasound. While Afghan surgeons are still scarce, Tajik doctors are able to cross the border to assist Afghan healthcare providers in conducting certain surgical procedures such as cataract removal.
Since most Afghans in the border districts do not have passports, it is not possible to organize training for Afghans in Tajikistan. Visa restrictions (and the occasional outright ban on visas for Afghans) make travel to Tajikistan difficult even for those with passports. To mitigate this situation, the AKDN cross-border health programme often provides training opportunities in Faizabad (and occasionally in Kabul) for Afghan health workers and professionals from Badakhshan’s border districts.
Insecurity, or the threat of insecurity, can lead to the border being closed, and these closures can last indefinitely, with scant details being released in such cases about the planned reopening of the border. This brings difficulties for participants in the cross-border healthcare programme. In addition, Tajik doctors travelling to Afghanistan to carry out procedures have to cope with a lack of available medicines within Afghanistan, limiting their ability to provide treatment. Nonetheless, as stated above, access to healthcare for citizens of Badakhshan province has improved markedly in recent years. Some interviewees64 were sceptical of the importance of shared culture in encouraging cross-border collaboration. While cultural and linguistic ties were seen as helpful, there remain significant differences in, for instance, systems of education, governance and the social and political environments between the two countries. Indeed, many of the Tajik doctors participating in the scheme are not from the GBAO. Instead, a shared spirit among medical practitioners regarding the importance of providing healthcare was seen as the driving force behind the project’s success.
Lessons learned
It is somewhat ironic that India and Pakistan, along with Iran, are in competition to attract Afghan patients. However, this competition provides a positive narrative as regards engaging with Afghanistan. Given that healthcare in Afghanistan is likely to remain poor for the foreseeable future, in an ideal world the three countries could engage in dialogue to assess in which fields they each have comparative advantage.
In some respects, the geography of Badakhshan provides the obvious rationale for cross-border healthcare collaboration. Scattered communities on the Afghan side of the border are at certain times of the year cut off from any access to secondary or tertiary healthcare in their own country, yet medical facilities are available over the border.
Improving access to healthcare in Afghanistan should be a priority on its own merits, but also provides a means of enhancing stability in the country. Conflict has wrecked the country’s healthcare system, prompting most medical professionals to leave the country. For those in need of healthcare, the costs involved – in terms of both money and time – can push families into poverty, in turn potentially increasing the risk of radicalization.
At the same time, governmental weakness within Afghanistan is seen as a powerful recruiting message for non-state actors. Extending the remit of governance is paramount for the Afghan state. Yet the provision of public goods is a contested issue in many fields of government – such as education which, like security, is regarded as a divisive area. Healthcare (with very few exceptions, notably the issue of vaccination to prevent the transmission of polio) is one of the less politically contentious fields. Any action by Afghanistan’s neighbours to support healthcare provision for Afghans should be seen in a positive light.
54 Tehran Times (2018), ‘Iran’s small share of Afghan health tourists should be addressed’, 1 December 2018, https://www.tehrantimes.com/
news/430051/Iran-s–small-share-of-Afghan-heath-tourists–should-be-addressed (accessed 14 May 2019).
55 Chowdary, S. (2017), ‘Medical tourist arrivals in India up 25%’, Business Standard, 22 April 2017, https://www.business–standard.com/
article/companies/medical-tourist-arrivals-in-india-up-25-117041900577_1.html (accessed 14 May 2019).
56 International Medical Travel Journal (2017), ‘India Medical Tourism Statistics Released’, https://www.imtj.com/news/india-medical-tourism-statistics-released/ (accessed 14 May 2019).
57 Economic Times (2017), ‘Medical tourism value in India to touch USD 9 bn by 2020: Govt’, 18 December 2017, https://economictimes.indiatimes.com/industry/services/travel/medical-tourism-value-in-india-to-touch-usd-9-bn-by-2020-govt/articleshow/62124646.cms (accessed 14 May 2019).
58 Chowdary (2017), ‘Medical tourist arrivals in India up 25%’.
59 Singh, V. (2018), ‘Pak losing Afghan medical tourism to North India’, The Tribune, 26 December 2018, https://www.tribuneindia.com/
news/punjab/pak-losing-afghan-medical-tourism-to-north-india/704169.html (accessed 14 May 2019).
60 Yousafzai, S. (2018), ‘K-P to focus on ‘medical tourism’ for Afghans’, Express Tribune, 12 November 2018, https://tribune.com.pk/story/1845426/1-k-p-focus-medical-tourism-afghans/ (accessed 14 May 2019).
61 Khodjamurodov, G., Sodiqova, D., Akkazieva, B., Rechel, B. (2016), ‘Tajikistan: health system review’, Health Systems in Transition, 18(1): pp. 1–114, http://www.euro.who.int/__data/assets/pdf_file/0007/308833/HiT-Tajikistan.pdf (accessed 14 May 2019).
62 De Haan, S. and Iskhakova, Z. (2006), Research for Health in Tajikistan: Strengthening the National Health Research System, Geneva: The Council on Health Research for Development, http://www.cohred.org/downloads/cohred_publications/rp4.pdf (accessed 26 Jun. 2019).
63 Khodjamurodov, Sodiqova, Akkazieva, Rechel (2016), ‘Tajikistan: health system review’.
64 For instance, interviewed in August 2018, the head of Shighnan health clinic in Afghanistan reflected on the ‘universality’ of medics’ commitment to save and improve lives; he emphasized the need to strengthen the human and ‘organic’ force that drives people to improve lives of those in need instead of presupposing cultural similarities would automatically lead to better cooperation. Tajik respondents also expressed similar sentiments. There was a recognition by Afghans and Tajiks who were interviewed that facilitating interactions and people-to-people contacts would foster long-term cordial relations regardless of whether cultural ties are seen as strong.