The Infrastructure That Survived
Afghanistan's family planning system reached 70,000 patients in 2024 and averted an estimated 340 maternal deaths, according to DKT Afghanistan, despite operating under a government hostile to women's autonomy. This persistence reveals something unexpected about development infrastructure: the components built through religious legitimization, private distribution networks, and clinical integration points have proven more durable than the ministries that once claimed credit for them. Modern contraceptive use doubled from 10% in 2003 to 16% currently among women of reproductive age, per UNFPA Afghanistan, and that gain has held roughly steady even as the government that set national targets collapsed. The question isn't whether family planning can survive hostile conditions, but which specific mechanisms create resilience and which were always dependent on political will.
Three Pillars Built to Outlast Governments
The system's durability rests on infrastructure designed to function independently of state capacity. UNFPA organized three conferences that brought together 580 influential religious leaders and community gatekeepers to address the widespread misconception that contraception violates Islamic principles, according to UNFPA Afghanistan. This theological intervention created a permission structure that operates through mosque networks and community authority rather than government messaging. When the state changes hands, the religious leaders who granted permission remain in their communities. The investment wasn't in changing policy but in changing the people who interpret religious law at the local level.
The second pillar operates entirely outside government control. DKT Afghanistan works through more than 3,800 private outlets across 13 provinces, delivering services that reached nearly 40,000 family planning clients in 2024. This network functions parallel to Afghanistan's Basic Package of Health Services, which emphasizes reproductive and maternal health but depends on ministry coordination and provincial health officers. When government systems falter, private pharmacies and clinics continue operating because their incentive structure runs through patient fees and supply relationships rather than budget allocations. The 298,000 unintended pregnancies averted by DKT's work in 2024 happened through a distribution system that never required ministerial approval for each transaction.
The third pillar embeds family planning into moments when women are already accessing healthcare. In 2019, the Ministry of Public Health and WHO established postpartum and post-abortion family planning "corners" in 25 health facilities in Kabul and Herat provinces, according to UNFPA Afghanistan. These integration points catch women at decision moments rather than requiring separate family planning visits, which cultural barriers often prevent. The model recognizes that a woman who has just delivered or experienced pregnancy loss is simultaneously most motivated to prevent immediate subsequent pregnancy and most likely to be in a healthcare setting. Integration removes the barrier of seeking contraception as a standalone, culturally fraught act.
Where the System Shows Fractures
Yet survival isn't the same as effectiveness, and the infrastructure's limits become visible in the data gaps. Modern contraceptive prevalence at one month postpartum stands at just 6%, jumping to 22% by six months postpartum, according to UNFPA Afghanistan. That disparity reveals the immediate postpartum window closing without adequate institutional support. The most effective intervention point, when women are both motivated and accessible, is the one collapsing fastest. A 2019 baseline assessment of the 25 facilities with family planning corners found only half had intrauterine device and implant insertion and removal kits, just 13% had implants available, and only 20% had family planning counseling tools. The infrastructure exists on paper, but the supply chains and training systems that make it functional depend on coordination that has deteriorated.
The scale of unmet demand clarifies what maintenance-level operation means in human terms. One in two currently married Afghan women aged 15 to 49 wants to delay their next pregnancy by at least two years (24%) or stop having children entirely (26%), according to UNFPA Afghanistan. Yet unmet need for family planning stands at 25% among women of reproductive age. That gap represents roughly one million women who have decided what they want but cannot access it. The Ministry of Public Health had committed to increasing modern contraceptive prevalence to 30% and reducing unmet need to 10% by 2030, but those targets now exist in a policy document disconnected from implementation capacity. The infrastructure can maintain current users but cannot expand to meet articulated demand.
What Development Investments Actually Built
Afghanistan has become an accidental experiment in which components of health systems have roots versus which were performative. The religious leader engagement created durable theological permission because it operated through existing authority structures rather than creating new ones dependent on donor funding. The private distribution network survived because it never required government capacity to function. The clinical integration model proved its concept but revealed its dependence on supply chains and trained providers, both of which require sustained institutional support. UNFPA's training of 120 women civil society leaders, 20 journalists, 22 provincial reproductive health officers, and service providers at more than 350 health facilities built individual capacity, but that capacity disperses when the coordinating institutions collapse.
The contrast between what persisted and what deteriorated reveals the difference between systems change and program implementation. Training 33 service providers in IUD and implant insertion and removal, with an additional 30 receiving refresher training, creates skilled individuals but not a self-sustaining training pipeline. When those providers leave their positions or need updated skills, the training system that created them no longer functions. The private outlets, by contrast, train their own staff because their business model requires it. Religious leaders train their successors because that's how religious authority transfers. The infrastructure that survived was the infrastructure that didn't require ongoing external coordination to reproduce itself.
The Maintenance Trap
The current situation demonstrates both the possibility and the limits of resilient systems under hostile conditions. Currently, approximately 22% of Afghan couples use any contraceptive method, and 49% of deliveries are attended by a skilled provider in an institution, with 59% of pregnant women receiving antenatal care, according to UNFPA Afghanistan. These access points remain functional, creating ongoing opportunities for family planning integration. Spacing pregnancies by more than two years can reduce maternal mortality by 30% and infant mortality by 10%, meaning the existing infrastructure continues preventing deaths even at maintenance capacity. But maintenance capacity serves current users while the population grows and unmet need accumulates.
The barriers that existed before the government change remain in place: lack of comprehensive information, inadequate counseling skills among health service providers, limited access to contraception, and cultural factors that restrict use, according to UNFPA Afghanistan. These barriers require active intervention to overcome, not just infrastructure maintenance. The religious leaders who granted theological permission can sustain that permission, but they cannot expand contraceptive access without supplies, trained providers, and functional referral systems. The private network can maintain its 3,800 outlets, but expanding into underserved provinces requires capital investment and regulatory stability that current conditions don't support.
What Resilience Costs
The Afghan family planning system's persistence under adverse conditions validates certain development approaches while exposing others as dependent on political alignment. Building through existing authority structures, creating economically self-sustaining distribution, and integrating into existing healthcare encounters all proved more durable than capacity building within government ministries. But durability without growth means the infrastructure serves a static population while need expands. The 340 maternal deaths averted by DKT's work in 2024 represent lives saved by a system operating at a fraction of potential capacity, serving 40,000 family planning clients in a country where millions want but cannot access contraception. The infrastructure survived, which is more than many predicted. Whether survival without growth constitutes success depends on whether the goal was ever to build systems that could expand under any government, or just to maintain gains until political conditions improve.