Kabul - Health care in Afghanistan has largely failed to address the needs of its people, who continue to deal with the violence of a decade-long conflict, according to a new report from Medecins Sans Frontieres.
"Between Rhetoric and Reality", published on Tuesday, states that during a 12-month period, 19 percent of people had a family member die due to lack of access to proper health facilities.
Speaking to Al Jazeera, Benoit De Gryse, MSF Afghanistan country manager, said that although gains have been made in the 13 years since the removal of the Taliban, lack of access to healthcare is still a significant issue.
"Much of the reporting of the situation today is a bit too positive. Afghanistan is still after all, a country at war."
According to the 48-page report, the major factor restricting access to proper care is money.
A third of those surveyed said they had to spend an average of $40 during a recent illness or injury. In a nation where one-third of the population is unemployed and nearly half the people live below the poverty line, the costs can be extremely prohibitive.
Distance was the second largest obstacle to healthcare. Of the 800 patients and caretakers surveyed during a six-month period, the report found that 12 percent had to travel for more than two hours to reach the nearest facility.
Mustafa Sahibzada, a doctor at the Maiwand Teaching Hospital in Kabul, said transportation could often exacerbate problems for patients suffering from bone damage .
In Kabul we are fortunate that we have specialists, but many are afraid to go out into the provinces specifically because of the dangers.
"We see many patients who for much of the journey from the provinces must travel by carriage on bumpy and treacherous roads."
In the northern province of Kunduz, where MSF operates a trauma centre, 27 percent of respondents reported traveling more than two hours with a seriously injured person to reach the facility.
De Gryse said for many Afghans, living only 10 or 15 kilometres from city centres greatly reduces their chances of receiving proper treatment.
But doctors speaking to Al Jazeera said that, in some provinces, even living in city centres is not a guarantor of proper care. In the province of Ghor, for example, patients must often share beds.
The war contributed to 18 percent of the difficulties for Afghans seeking treatment.
Sahibzada, the Kabul-based doctor, said increasing violence has also affected the ability of doctors to reach patients. "In Kabul we are fortunate that we have specialists, but many are afraid to go out into the provinces specifically because of the dangers." This, said Sahibzada, greatly reduces the quality of care outside the urban centres. "In many places you have someone who studied pharmacy or nursing for short periods treating entire patient-loads for illnesses they have little to no understanding of."
De Gryse said poor planning by international actors also contributed to uneven distribution of resources.
An overemphasis on "threat-based" aid over "needs-based" assistance has led to a situation where "a disproportionate share [of assistance is] directed towards insurgency-affected areas … regardless of whether this was where the greatest needs were to be found."
A number of international non-governmental organisations said the report "took an opportunistic approach, sidelining their humanitarian expertise and principles for the sake of the development funding available".
However, the government too has made missteps, with the naming of several health facilities as registration and polling centres for April's presidential election has proven especially problematic.
"This places the health facilities at increased risk of attack, damages the perception of health centres as neutral spaces to provide medical care, and puts the lives of health workers and patients in danger," the report said.