{
  "abstract": "Introduction Emergency, critical and operative (ECO) services are essential pillars of a resilient healthcare system and are integral to achieving universal health coverage, especially in post-conflict low- and middle-income countries like Afghanistan. The objective of this study is to evaluate the capacity, safety and availability of ECO services, and to understand their integration relation with barriers, facilitators and system level factors contributing to the delay to receive ECO care in nine Afghan provinces.Methods This study used a concurrent mixed-methods approach with explanatory data analysis and interpretation. Quantitative data were obtained from adapted WHO Harmonized Health Facility Assessment and WHO Surgical Assessment Tool, complemented by qualitative interviews with hospital directors, surgeons and gynaecologists from 11 Ministry of Public Health-led facilities including maternal, district, provincial and regional hospitals across nine provinces. The dimensions of staff, supplies, infrastructure, safety protocols, training, and surgical and obstetric/gynaecological capacity were assessed. Interviews explored providers’ perspectives on accessibility, referral systems, training and gendered barriers to care.Results Data revealed significant gaps in workforce, safety, emergency protocols, anaesthesia staff, resuscitation equipment and diagnostic tools. No facility met the WHO benchmark for essential surgical services. The 11 interviews confirmed systemic fragmentation, lack of communication across facilities, informal referrals, frequent supply shortages and restricted access to care for women, exacerbated by social and cultural norms. Staff often worked without pay, and training was irregular.Conclusions Afghan ECO care is fragmented and staffing and structural limitations and socio-political factors contribute to fatal delays. Leveraging existing processes such as the non-governmental organisation networks—especially amid critical underfunding for international agencies—may offer pragmatic low-cost strategies to strengthen ECO services in the Afghan post-conflict context, while future work should focus on people-centred needs assessment.",
  "authors": [
    {
      "affiliations": [
        "CRIMEDIM, Center for Research and Training in Disaster Medicine, Humanitarian Aid and Global Health, Università degli Studi del Piemonte Orientale Amedeo Avogadro, Novara, Italy",
        "Department for Sustainable Development and Ecological Transition, Università degli Studi del Piemonte Orientale Amedeo Avogadro, Novara, Italy"
      ],
      "name": "Paolo Rodi"
    },
    {
      "affiliations": [
        "EMERGENCY Ong Onlus, Milan, Italy"
      ],
      "name": "Francesca Bocchini"
    },
    {
      "affiliations": [
        "EMERGENCY Ong Onlus, Milan, Italy"
      ],
      "name": "Ilaria Mencattini"
    },
    {
      "affiliations": [
        "EMERGENCY Ong Onlus, Milan, Italy"
      ],
      "name": "Ghulam Ali"
    },
    {
      "affiliations": [
        "EMERGENCY Ong Onlus, Milan, Italy"
      ],
      "name": "Mirza Sayed Nadeem"
    },
    {
      "affiliations": [
        "EMERGENCY Ong Onlus, Milan, Italy"
      ],
      "name": "Mohammad Hanif"
    },
    {
      "affiliations": [
        "EMERGENCY Ong Onlus, Milan, Italy"
      ],
      "name": "Mohammad T Alizai"
    },
    {
      "affiliations": [
        "CRIMEDIM, Center for Research and Training in Disaster Medicine, Humanitarian Aid and Global Health, Università degli Studi del Piemonte Orientale Amedeo Avogadro, Novara, Italy",
        "Department for Sustainable Development and Ecological Transition, Università degli Studi del Piemonte Orientale Amedeo Avogadro, Novara, Italy"
      ],
      "name": "Luca Ragazzoni"
    },
    {
      "affiliations": [
        "CRIMEDIM, Center for Research and Training in Disaster Medicine, Humanitarian Aid and Global Health, Università degli Studi del Piemonte Orientale Amedeo Avogadro, Novara, Italy",
        "Department for Sustainable Development and Ecological Transition, Università degli Studi del Piemonte Orientale Amedeo Avogadro, Novara, Italy"
      ],
      "name": "Francesco Barone-Adesi"
    },
    {
      "affiliations": [
        "CRIMEDIM, Center for Research and Training in Disaster Medicine, Humanitarian Aid and Global Health, Università degli Studi del Piemonte Orientale Amedeo Avogadro, Novara, Italy",
        "EMERGENCY Ong Onlus, Milan, Italy"
      ],
      "name": "Alessandro Lamberti-Castronuovo"
    },
    {
      "affiliations": [
        "CRIMEDIM, Center for Research and Training in Disaster Medicine, Humanitarian Aid and Global Health, Università degli Studi del Piemonte Orientale Amedeo Avogadro, Novara, Italy",
        "Department for Sustainable Development and Ecological Transition, Università degli Studi del Piemonte Orientale Amedeo Avogadro, Novara, Italy"
      ],
      "name": "Martina Valente"
    }
  ],
  "title": "Emergency, critical and operative care in Afghanistan: pathways to overcoming fragmentation and strengthening access in a post-conflict setting—a mixed-method study",
  "uid": "ad59ef86-a4be-5256-98f0-7c2c9753eb19"
}