US-funded Kabul clinic forced to close because Health Ministry won't fund it

By next month, there will be no more doctors at a clinic once deemed a model in Afghanistan. The shelves of the pharmacy are already empty. The modern X-ray and dialysis machines, rarities in one of the world's poorest countries, sit unused in a building that was inaugurated by a top US general.

"They might as well turn it into a soccer field," he says.

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 in the state of Florida. 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 US$750,000. At the time, the military had billions to spend as part of its foreign assistance programme, called the Commander's Emergency Response Programme.

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 non-profit organisation that provides medical assistance to developing countries, donated more than US$100,000 in equipment. The World Health Organisation donated vaccines. The Canadian government donated a refrigerated storage container.

The enterprise, like many development projects in Kabul, 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 US Agency for International Development (USAid) and the World Bank, the Afghan Ministry of Public Health has a budget of more than US$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 to the standards envisioned by US donors would cost about US$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, General Karl Eikenberry, then the top US commander in Afghanistan, led the ground-breaking 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 risen 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 US 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," says 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 charge anyone 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 rejected 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 US$400 per year, nurses US$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 last year, most of the government's funding had vanished. Mojadidi says he went to the public health minister and pleaded for money but was told none was available. He quit his advisory position shortly after.

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 says. "We are providing financial support."

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 visited President Hamid Karzai carrying a glossy brochure of the clinic, which described its "American standards". But the meeting didn't produce concrete promises. Mojadidi pleaded for more funds from visiting Pentagon officials but says 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 arriving for treatment. Aini, the last doctor at the clinic, had begun to apply for jobs at Western non-governmental organisations in Kabul.

"There's no money and medicine. What else can I do here?" Aini says. "Because of the mismanagement of the government, now nothing is possible."

In September, the Office of the US Special Inspector General for Afghanistan Reconstruction found that because of "financial management deficiencies" at the Ministry of Public Health, US$236 million in USAid assistance was potentially subject to "waste, fraud and abuse".

Although the Kabul clinic received money from the military, not USAid, the fundamental problem is the same: how can US 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 US military grants. Oversight often ends when troops leave a particular province. About US$1.5 billion in commander's programme funds were spent from 2004 to 2011.

"We are not aware of any US military programme in Afghanistan that requires the monitoring and evaluation of a facility's use once we have transferred it to the Afghan government," says Jeffrey Hawk, a spokesman for US 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 says the Afghan government cannot provide support for clinics built by the US military in areas torn by conflict. But the Kabul clinic is just a few kilometres from the headquarters of the US-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 says, standing in the empty hospital. "Thanks to the government's mismanagement, we lost everything."