Urban Livelihoods in Afghanistan - the Afghanistan Research and ...

Synthesis Paper SeriesFigure 4. Frequency of expenditures on health problems (recorded during monthly monitoring interviews)Kabul75%Herat68%Jalalabad 90%quantitative results. On almost every visit bythe research team, respondents reportedserious health problems encountered bydifferent family members in any given month.Disability, chronic illness and children beingsick on a regular basis lead to huge difficultiesin coping with necessary health expenditures.As a result, urban families fall easily intodebt, or lean heavily on relatives and socialnetworks for support.It is important to stress that the urban poor’ssusceptibility to health problems is acumulative result of inadequate shelter, useof polluted water sources and the lack ofsanitary waste and sewage disposal systems.Moreover, poor health is a major determinantof household vulnerability. Serious illness ofthe breadwinner, or the health demands ofa sickly child or an aging family member canpush poor households to insurmountable levelsof poverty. This becomes particularly evidentwhen the earner in a one-income family fallsill; the household will have to find ways tocope with the loss of income. If the degreeof income diversification is low, the wellbeingof the entire household can be at risk.In general, there was no evidence ofpreventive healthcare sought by the householdsamples. The trend was to act only whenconfronted by a health issue, rather than beproactive about healthcare. In many cases,coping with an illness or disease requiresmobilising resources (i.e. money and credit)from social networks. But with the high costof healthcare, poor urban families could notafford to make it a priority.Box 2. Illness, coping and vulnerabilityThere are countless examples in all study sites ofchronic sickness and ill health affecting poor urbanhouseholds and seriously hampering their effortsto manage a sustainable livelihood. People do nothave the means to cope with a sudden health shock,more often than not requiring them to go intodebt, to settle an early marriage arrangement fora daughter, or to delay necessary treatment.Chronic illness likewise puts a heavy burden onpoor urban households, with regular medicalexpenditures disrupting tight household budgets.Some examples illustrate the coping strategiespursued when it comes to health issues. The firstexample is from Kabul, where the disabled headof a household, who is a cart puller and singlebreadwinner, was hospitalised after an accident.Suddenly confronted with medical expendituresand total loss of income, the extended familyprovided support. Many visitors to the hospitalbrought gifts and money; his brothers, both mobilevendors also facing insecure situations, providedwhatever help they could; neighbours stepped inand contributed; and the local shopkeeper gavehim a bigger loan to help overcome the difficulttime. Another example is taken from Jalalabad,where the household sold jewellery, which cameas part of the marriage arrangement of its femalehead, to cope with expenditures and income lossafter her husband suffered a blood infection. InHerat, one household settled a marriage for itssix-year old daughter to afford the regularexpenditures required for the treatment of theaging head of the family. A similar strategy wasapplied by a household in Jalalabad, where thebride price for a daughter engaged in her earlyteens is gradually being paid to the household andpresently serves as the means to treat thechronically sick head of household. Some families,however, lack the physical assets to dispose of, ortheir social networks are not able to providesufficient support. This defencelessness have ledto fatal consequences. As revealed during interviewsin Pul-i-Khumri and Mazar-i-Sharif, many familieslost a child to illness, which may have beentreatable, even preventable, if only medicalexpenses were affordable.30Afghanistan Research and Evaluation Unit