“They might as well turn it into a soccer field,” he said.
As the United States’ longest war winds down, hundreds of aid projects are being handed over to Afghan ministries, which sometimes lack the capacity or interest to sustain what foreign donors started. The Urgent and Primary Care Clinic in Kabul is a small but telling example: one of the few medical facilities in Afghanistan with state-of-the-art American equipment, a place that once saw nearly 5,000 patients per month and will soon see none.
The clinic was the brainchild of Asad Mojadidi, an Afghan-born doctor who moved to the United States in 1982 and practiced in Jacksonville, Fla. The doctor, who comes from one of Afghanistan’s most influential families (his brother was once president), decided to use whatever clout he had to improve the country’s failing health-care system.
He pitched his idea for the clinic to contacts at the Pentagon, who told him that they could commit $750,000. At the time, the military had billions to spend as part of its foreign assistance program, called the Commander’s Emergency Response Program (CERP).
Buoyed by the Pentagon’s investment, Mojadidi secured hundreds of thousands of additional dollars from private donors and Western aid groups and embassies.
America’s Heart, a Florida-based nonprofit organization that provides medical assistance to developing countries, donated more than $100,000 in equipment. The World Health Organization donated vaccines. The Canadian government donated a refrigerated storage container.
The whole enterprise, like many development projects here, was predicated on the Afghan government’s promise to assume responsibility for the clinic once it was built and outfitted. In theory, that shouldn’t have been a problem. Thanks to international support, especially from the U.S. Agency for International Development (USAID) and the World Bank, the Afghan Ministry of Public Health has a budget of more than $300 million a year.
As a senior adviser at the Ministry of Public Health, Mojadidi thought he was in the right position to direct resources to the project. He estimated that keeping the clinic running at the standards envisioned by U.S. donors would cost about $100,000 per year. But that money never arrived. Mojadidi watched as the Afghan government refused to pay even for electricity.
When it opened, the clinic had 42 employees, including six doctors, six nurses, and several pharmacists and X-ray technicians. Soon after Gen. Karl Eikenberry, then the top U.S. commander in Afghanistan, led the groundbreaking ceremony, patients flocked to the medical facility from across the country.
It became part of Afghanistan’s rapidly improving public health sector, where some of the most lauded assistance projects were having a noticeable effect. A 2011 USAID survey found that life expectancy in the country had jumped from 42 years — the second-lowest rate in the world — to about 62 years from 2004 to 2010.
Despite that improvement, the majority of Kabul’s clinics and hospitals that have modern equipment are private — and affordable only to the elite. Afghan government clinics are free but generally very basic. The Urgent and Primary Care Clinic’s directors and doctors hoped to use their donations — and their connection to the U.S. medical community — to provide quality care for Afghanistan’s massive underclass.
“We operated in a modern way, with a higher ethical standard than any other Afghan hospital,” said Habibullah Aini, a doctor, who will quit the clinic this month. He has not been paid since July.
Initially, Mojadidi and the Ministry of Public Health charged small fees to some patients, depending on their income, but decided not to seek any payment from those living in abject poverty, especially widows, people with disabilities and orphans. Such a system, they thought, would bring at least some money directly to the clinic — enough to pay for medicines, maybe.
The Afghan Justice Ministry nixed that plan a year later, arguing that the government could not accept money from patients. Still, Mojadidi thought, the Ministry of Public Health, which had expressed gratitude to the Pentagon for its initial donation, would have no problem filling the small gap in funds, given its pledge to support the clinic.
The hospital’s needs were modest: Doctors made $400 per month. Nurses made $150. Many of the medicines were donated. The clinic had all the equipment it needed.
Initially, the government contributed to the staff members’ salaries. But by 2012, most of the government’s funding had vanished. Mojadidi said he went to the public health minister and pleaded for money but was told that none was available. He resigned from his advisory position shortly thereafter.
Kanishka Baktash, a spokesman for the Ministry of Public Health, denied that the clinic was on the verge of shutting down.
“The clinic is active,” he said. “We are providing financial support.”
But when a reporter visited the clinic this month, there was no sign of activity. Many rooms were locked. Baktash would not say how much money the ministry is providing, nor how it is being spent.
Out of options, Mojadidi went to President Hamid Karzai with a glossy brochure about the clinic, which described its “American standards,” but the meeting didn’t produce any concrete promises. He pleaded for more funds from visiting Pentagon officials but said he received no additional assistance.
After relying on small private donations for more than a year, Mojadidi acknowledged this summer that the clinic would have to close, even though patients continued coming for treatment. Aini, the last doctor at the clinic, had begun to apply for jobs at Western nongovernmental organizations in Kabul.
“There’s no money and medicine. What else can I do here?” Aini said. “Because of the mismanagement of the government, now nothing is possible.”
A fundamental problem
In September, the Office of the U.S. Special Inspector General for Afghanistan Reconstruction found that because of “financial management deficiencies” at the Ministry of Public Health, $236 million in USAID assistance was potentially subject to “waste, fraud and abuse.”
Although the Kabul clinic received funding from the military, not USAID, the fundamental problem is the same: How can U.S. officials ensure that their investment isn’t squandered as Afghan ministries take on more responsibility for the projects?
That’s a particular problem for the thousands of projects that received one-time U.S. military grants. In such cases, oversight often ends when troops leave a particular province. About $1.5 billion in CERP funds were spent from 2004 to 2011.
“We are not aware of any U.S. military programs in Afghanistan that require the monitoring and evaluation of a facility’s use once we have transferred it to the Afghan government,” said Jeffrey Hawk, a spokesman for U.S. forces in Afghanistan. “As a sovereign entity, the Afghan government determines how to budget and allocate funds for various needs and requirements, including staffing, operations and maintenance.”
Baktash said the Afghan government could not provide support to workers at clinics built by the U.S. military in areas torn by conflict. But the Kabul clinic is just a few miles from the headquarters of the U.S.-led International Security Assistance Force and close to the seat of Afghan power.
“There was so much potential, and look at what is left,” Mojadidi said this month, standing in the empty hospital. “Thanks to the government’s mismanagement, we lost everything.”