Conducting Health Research in the Current Afghan Society: Challenges, Opportunities, and Recommendations

Background

Afghanistan, a low-income country in Central Asia with a population of more than 35 million people, is experiencing a diverse set of problems resulting from a 40-year conflict and political upheavals.¹ In the past 5 years alone, Afghanistan has witnessed the 2021 government collapse, global sanctions, COVID-19, and arduous economic conditions.^1,2 Moreover, the unprecedented crises have imposed a heavy toll on the health system.¹ The Afghan population is highly vulnerable to many health-related risks due to limited access to appropriate healthcare and living in a very vulnerable setting deprived of even basic human needs and rights.^1,2

For the last two decades, Afghans, with the generous assistance of the international community, have somewhat managed to develop and equip a functional healthcare system in the country. However, large gaps in access, coverage, and quality of health services persist at several levels across the country.¹ To make meaningful progress towards a superior health care system in the country, enhancing health research activities must be a high priority agenda for the government, international community, and health sector stakeholders.

On a global scale, research initiatives in different areas of the health system have had unparalleled proliferation in the last two decades.³ Research is now more commonly integrated, for instance, into the better management of diseases by enhancing our understanding of diseases, improving diagnostic and treatment options, and enabling more patient-centered and data-driven approaches to healthcare.^3,4 In a broader context, incorporating health research into governance, policymaking, and quality improvement initiatives pledges to enhance healthcare systems’ overall effectiveness and efficiency.^4,5 It promotes evidence-based decision-making, increases transparency, and galvanizes better health outcomes for individuals and communities.³

Despite the increasing importance of health research in developing new therapies and facilitating notable progress in public health, the landscape of health research in Afghanistan remains profoundly deficient.⁶ This deficiency may have emerged from the absence of health research institutions, a scarcity of skilled and knowledgeable health researchers, and the impediments encountered in financial, ethical, and socio-cultural domains.⁶ Additionally, amid the collapse of the internationally assisted Afghan government in August 2021, the trajectory of the nascent/rudimentary Afghan health research system is poised to deteriorate significantly.^6,7 This article will describe existing challenges and opportunities and highlight recommendations for health research in Afghanistan.

Current Context and Challenges

Strengthening health research capacity is considered one of the most cost-effective and sustainable means of identifying challenges, needs, and priorities in the health system.^4,5 However, health research has neither been prioritized nor has received the attention it calls for throughout Afghan history.⁶ This low prioritization stems from its prolonged conflict, persistent political instability, a scarcity of skilled and knowledgeable health researchers, and under-resourced health infrastructure.⁷ Moreover, the lack of a favorable and conducive environment for health research is another key challenge to building a competent health research system in the country.

The assistance from international society and the innate willingness of prominent public medical institutions, hospitals, and their academia galvanized the establishment of health research centers (RCs) as integral components of their research infrastructure.⁸ Even though independent researchers have established a few research centers within the private sector, they often operate without a standard regulating system.⁸ Additionally, it is well-known that research centers are pivotal to fostering meaningful research. The currently functional Afghan research centers are very strained in terms of both human and financial resources.⁸ In these academic institutions, senior lecturers and health professionals carry out much of the health research endeavors, usually in conjunction with their academic responsibilities.⁹ In the last two decades, however, with the assistance of the international society through offering copious post-graduate training opportunities overseas, Afghan researchers have somewhat managed a growing national health research portfolio.⁹ The concurrent evolving socio-political circumstances somehow created distinct difficulties for those conducting health research in such situations. These multi-faceted challenges include the scarcity of post-graduate training opportunities, diminished motivation, and inadequate research funding.^6,7 Additionally, the collapse of the internationally assisted Afghan government resulted in an enormous migration of health researchers.^5,6

Health research activities are usually limited to the metropolitan health facilities where the researchers deliver the service.^6,8 Access of researchers to farther communities and rural populations is challenging and problematic.⁶ The authorities mandated additional restrictions imparted to the challenges that community-based research initiatives may encounter.^6,9

It is rather hard to overstate the significance of technology-based research tools in the research domain. It has reformed how the research is conducted across various fields, enabling more efficient data collection, analysis, and dissemination of findings.^10,11 The lack of access to such research tools in Afghanistan poses a significant challenge, which hampers the efficiency and effectiveness of research activities and makes tasks such as data analysis, modeling, and information management quite arduous.^5,6

The Afghan Ministry of Public Health (MoPH) established the inaugural Institutional Review Board (IRB) dedicated to health research in 2005.⁸ While approximately ten non-registered IRBs currently function in the country, they are mainly present in major socio-economic and geopolitical cities.⁸ Although the national and local IRBs provided ethical and regulatory support to researchers in 2005, field-based surveillance is deficient, especially in remote and conflict-ridden areas.^6,8

Nowadays, Afghan medical institutions and private research organizations publish 3 to 4 international medical journals.¹² However, to our knowledge, none of the Afghan journals are indexed in major international databases such as Medline, PubMed, Web of Science, and Scopus. It may indicate that Afghan journals reporting health research lack the prerequisite satisfactory quality for indexing in international databases.

Afghanistan contributed 120 research papers to international academic journals in 2020. This number signifies poor academic performance.¹² Moreover, in research publications, the quality problem of these papers has been widely recognized, and many journals that published these papers turned out to be predatory.

As a resource-deprived country, Afghanistan does not devote many financial resources to research.^6,12 It sounds understandable in the poorest country of the world where other immediate pressing needs deserve attention. The lack of donor funding has imparted new limitations and complexities to Afghan health research capacity.^12,13

Opportunities for Health Research

In the current post-conflict scenario in Afghanistan, multiple opportunities exist within health research that may improve healthcare outcomes and address the most pressing health problems the Afghan population encounters. Expansion of research in five essential domains, such as mental health, women’s reproductive health, COVID-19, clinical practice guidelines, and other key health concerns (including communicable and non-communicable diseases) should be prioritized because of the demonstrated need in these areas.

The nearly half-a-century-long conflict in Afghanistan has led to incalculable mortalities, morbidities, and millions of internally displaced persons (IDPs).^1,2 For instance, combat-related mental health conditions can be intense and long-lasting.¹ Factors that immensely increase vulnerability, such as poverty, unemployment, and illiteracy, are prevalent in Afghanistan.^14,15 In light of the underreporting of mental health conditions, the authentic and multidimensional burden of the conflict remains unknown.¹⁵ The latter enigma underscores the urgency to enhance mental health research that may provide insights into humanitarian assistance and the development of evidence-based bio-psycho-social interventions.

The substantial reductions in mortality from pregnancy-related diseases among Afghan pregnant women have been one of the success stories of the internationally assisted Afghan government and its international allies.¹⁶ Despite the constant efforts toward a quality health system and clinical excellence, pregnant women in Afghanistan are still at high risk for several pregnancy-related diseases due to limited access to appropriate healthcare services.¹⁷ Identifying and mapping causes for lower utilization of maternal health services in Afghanistan would be the first step to improving maternal and child health. Additionally, qualitative research may galvanize the provision of a detailed exploration of the socio-cultural and political factors influencing maternal health services utilization that assures the promotion of safe motherhood.

Over the past three years, the ongoing COVID-19 pandemic has led to unparalleled suffering on social and individual levels in developing and developed countries.^18,19 The impact of the pandemic on individuals and communities in Afghanistan is uncertain.^20,21 Rapid, actionable, and locally relevant research is highly warranted to strengthen the undermined health system to mitigate future disasters and pandemics. To address this lacuna, we recommend a multidisciplinary effort of clinicians, epidemiologists, economists, virologists, behavioral scientists, anthropologists, implementation researchers, and others.

Current guidelines for clinical practice in Afghanistan are based mainly on international guidelines and expert opinions. Several studies have indicated that international clinical guidelines warrant regional validation to reflect, at least, socio-cultural discrepancies.²² Standardized guidelines on diagnosis, treatment, comorbidity management, and palliative care, to name a few, should be developed utilizing findings of regional, national, and local clinical research and are widely accessible throughout the nation.

In addition, other imminent health concerns that Afghans encounter include infectious diseases, child health issues, Road Traffic Accidents (RTAs), and non-communicable diseases.²³ Health research may be highly relevant in understanding the prevalence, etiology, and effective interventions to control and manage these health problems.

Conclusion and Recommendations

This article reveals that health research in Afghanistan requires significant growth to meet the standards set on regional and global grounds. Therefore, we propose the following recommendations to strengthen health research in Afghanistan.

1. The development, employment, and enforcement of standards, regulations, and best practice guidelines for fair, accountable, and transparent health research processes are paramount. Key principles underpinning the development of guidelines/standards should entail a multifaceted approach, including stakeholders’ engagement, evidence-based practices, ethical prioritization, adaptability, and anticipation of future developments in health research.
2. The policymakers need to negotiate with potential stakeholders to discuss researchers’ encountered challenges in the health research field. Moreover, addressing the security concerns of health researchers must be a high priority agenda for the government.
3. The policymakers are to acknowledge that the national research policy calls for an exhaustive revision, in which issues pertinent to financing health research, effective dissemination of research results through the utilization of various mediums (ie, publications in biomedical journals, policy briefs, community workshops, and presentations at conferences and online platforms), and collaboration with international stakeholders are to be considered influential. Moreover, a top priority should be given to regional and international collaborative efforts that could maximize resources and skills available for health research and as well as builds capacity of the researchers to ensure the research aligns with the real needs of the population.
4. Establishing a credible mechanism for regulating and supporting national networks of researchers and regional centers of research excellence that may galvanize effective inter-sectoral, inter-ministerial, and inter-country research collaboration and coordination to address complex health challenges is compulsory.
5. The policymakers are to improve the quality of health research and publications by designing and implementing advanced and internationally approved training programs for the capacity building of health researchers.
6. Facilitated access to the latest research tools and credible medical journals is imperative. Priority should be given to technology-based research tools that aid in data management (statistical analysis tools like SPSS, R, and Stata), scientific writing (such as Grammarly), and detecting academic misconduct (plagiarism detecting tools like iThenticate and Turnitin).
7. Finally, the financial backing from the Afghan government and international funders to cover article processing charges (APCs) and proofreading services is of utmost importance. By providing monetary resources for APCs and proofreading services, financial barriers that often hinder researchers from publishing their work in reputable journals can be mitigated.

Health research has high value to society, yet it is challenging in the current economic and socio-political situation. We yearn to provide insights into the researcher’s encountered challenges to persuade policymakers to make the right decisions based on the suggested recommendations. Moreover, we recommend quantitative and qualitative studies involving researchers, which could provide a richer, more nuanced understanding of the lived experiences and challenges encountered in health research.