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As the plane left Lashkar Gar to Herat, I looked out at the dry earth chequered with green poppy fields and wondered if I would ever see Afghanistan again. I first worked there in 2000, when the Islamic Emirate of Afghanistan (IEA), also known as the Taliban, were in power. Some 22 years later and Afghanistan has gone full circle.

After 40 years of conflict, a relative calm has now settled and with the takeover of the IEA, has significantly .

Unfortunately, the humanitarian situation has gone the other way. Under the previous government, Afghanistan was almost completely on donor aid to and to power the economy. Now, much donor funding has been frozen, and sanctions have been imposed. Without foreign funding, the is close to collapse, and inflation has gone through the roof.

A bottle of oil, which would have previously cost a family about 700 Afghani (approx $8), now costs 1,800 (approx $20).Ěý

''For years, the public healthcare system has been unable to meet people’s needs, and this has only got worse since international funding was reduced.''

Climate change is also apparent. Afghanistan is in the grip of a prolonged drought, which has impacted crop production and driven poverty, hunger and displacement.

MSF’s work in Lashkar Gar is in support of the Ministry of Public Health’s 300-bed Boost Hospital.Ěý It’s an extremely busy facility and always has been, but the numbers of patients being seen today is unprecedented. In the emergency room, an average of 750 patients are being seen a day - that’s around 20,000 a month or 240,000 a year.

In the maternity ward, there are roughly 60 deliveries a day. My local hospital in London, Kings College Hospital, delivers roughly 6,000 a year. Boost delivers as many babies in a three-month period as Kings does on an annual basis.

The 40-bed paediatrics ward is similarly busy, currently operating at 198% bed occupancy. In fact, in every children’s ward, we are working with two patients per bed. The number of extremely sick children is devastating to witness.

Measles and malnutrition cases have skyrocketed. In previous years we would have been averaging 20-40 cases of measles a week as we approached the seasonal peak in spring, yet the week before I visited, 184 measles patients had been admitted into Boost.

Staff are overloaded yet while the numbers are overwhelming for them, they all spoke about how important it is that they keep going, caring for their fellow Afghans.

I spoke to a grandmother who was with her 11-year-old granddaughter. She came from a family of labourers who were scraping a living from whatever work they could pick up on a daily basis at the local market. Her grandchild had been admitted with TB meningitis and was desperately underweight for her age. She had been an inpatient for two months, the cost of which at any other facility would have been prohibitive for the family. She spoke movingly about what Boost, where MSF provides health care free of charge, represented for her granddaughter’s chances of survival.

The reasons behind the sharp increases in patient numbers are complex.

On the more positive side, with the transition of power to the Islamic Emirate of Afghanistan, the security situation particularly for the rural areas has dramatically improved. People can move around much more freely and it’s more possible for them to reach the provincial level facility.

A released by MSF in 2014, Between rhetoric and reality: The ongoing struggle to access healthcare in Afghanistan, documented that “for those who reached our hospitals, 40% of them told us they faced fighting, landmines, checkpoints or harassment on their journey”.Ěý People today can make the journey to Boost without that fear.

Other causal factors are not so positive. For years, the public healthcare system has been unable to meet people’s needs, and this has only got worse since international funding was reduced.

The same 2014 report cites serious shortcomings in healthcare provision, with a vast gap between the rhetoric of healthcare as an achievement of the international state-building efforts and the reality.

Today, people struggle to find even that very fragile provision and have to pay for their own medication in facilities that frequently run out. The virtual absence of healthcare in the rural areas then forces people to make the journey to Boost, costing them money they can barely afford for travel and often causing delays in seeking healthcare and worse outcomes. The number of very sick children that I saw in the paediatrics wards of Boost put a human face to those worse outcomes.

In the run-up to my visit, I was wondering what changes I would find. There are more cars on the roads and Kabul shows signs of significant investment. What particularly struck me is that despite the last 20 years of international donor investment, life in rural Afghanistan clearly remains extremely hard.

MSF is running five medical projects in Afghanistan today, several of them focused on women and children. We’re growing in every way: new projects envisaged, extra activities being planned, additional bed capacity being identified. Yet what MSF does in Afghanistan remains a drop in the ocean in the face of the need. For the individual Afghans that access our services, however, they remain vital.

Long-term support for Afghanistan means looking beyond the humanitarian system, which should not and could not replace a state apparatus and the public sector. It means addressing the banking and cash crisis in Afghanistan to ensure the economy can stabilise.

It also means a clear and coordinated allocation of humanitarian funds to avoid critical gaps, and to enable flexible funding mechanisms so that humanitarian organisations can adapt their activities to the changing context and needs. The people of Afghanistan must be remembered.

Vickie Hawkins is Executive Director of Médecins Sans Frontières/Doctors Without Borders (MSF UK). She has worked for MSF for over 20 years in a number of positions, including as project coordinator and country representative in Pakistan, Afghanistan, Myanmar and Zimbabwe.

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