Sana Safi, a young a doctor in Afghanistan, takes pride in her work, for she is among a shrinking group of female health experts in a country where women are banned from pursuing education or working in most sectors.

"I am making a real difference in the lives of my patients, especially women who have limited access to health care," the doctor told VOA on the phone from Nangarhar province.

But she also is afraid of drawing attention to herself for fear of reprisal and asked to be called Sana Safi to avoid revealing her real identity.

Many female doctors have left Afghanistan since the Taliban returned to power in August 2021. New women may not be entering the health sector any time soon, as the hardline de facto authorities banned medical education for women last December, leaving many final year students without a formal degree.

The edict was one in a long line of restrictions the Taliban's reclusive spiritual leader, Mullah Hibatullah Akhundzada, has placed on women, using extremely strict interpretation of Islamic teachings that he claims are divine commands.

The United Nations has called Taliban's treatment of women "gender apartheid."

Health is one of the few sectors in which Afghan women are allowed to work. Safi works in obstetrics and gynecology, one of the few specializations that women can practice.

Safi said she sees up to 40 women patients daily.

"What makes me sad about my work is the lack of resources, the restrictions on female health care workers, and the fact that many women are unable to get the medical attention they need due to cultural and political barriers," the doctor said.

Barriers that women face in accessing health care vary according to local culture across the war-torn, mountainous country.

"Patients in restricted [conservative] provinces are not allowed to come to the health facility without a mahram [male guardian]," a health sector researcher told VOA by phone from Kabul.

She asked that we call her Amina to protect her identity as her work requires cross-country travel to collect data.

"We have had these reports from the health facility level that the female who did not have the mahram with herself at the moment of delivery of the baby, she died because of this issue," the researcher said.

She said such restrictions are applied stringently in government-run health facilities in conservative towns but are largely ignored in private clinics, especially in urban centers like Kabul and Jalalabad.

A World Health Organization donor appeal issued last month said 14.5 million people, or 33 percent of Afghans, live in areas where primary health care cannot be accessed within a one-hour walk.

Since a majority of Afghans in the poverty-stricken country rely on state-run hospitals and health centers that provide care at little to no cost, women from poor households are forced to comply with the requirement of having a male guardian – who can even be a minor.

Amina, who travels with her husband for her research, told VOA that many female health workers also must bring a male family member to work with them in conservative parts of the country.

Taliban workers from the Ministry of Propagation of Virtue and Prevention of Vice, commonly called PVPV, routinely visit health centers to ensure compliance.

"They are regularly checking each health facility to see that each female health worker brought their mahram with herself or not," said Amina.

The researcher said that the requirement that a male family member must accompany a woman outside the house, though, existed in conservative parts of the country under the U.S.-backed regimes, as well, because of cultural norms.

The checks under Taliban are thorough.

"They check the attendance sheet and ask who is a particular doctor's mahram," the researcher said.

The restrictions come at a financial cost to families, while men who could work sit idle as chaperones.

From pharmacies to hospitals, Taliban have put men in charge. However, performing duties amid restrictions on the mixing of sexes is a challenge for them, too.

Pharmacy workers in areas under strict Taliban control are discouraged from giving medicine to women without mahram, and hospital chiefs are punished for holding meetings with female staff, according to Amina's research.

A hospital head in Badakhshan province spent two weeks behind bars after a meeting with female employees, Amina said.

Staff in private hospitals don't face similar restrictions.

"In emergency situations or when no other doctor is available, I may also assist male patients, if necessary," said Safi.

She told VOA she does not take a male guardian with her and that her employer provides transportation.

Amina said she believes Taliban are willing to look the other way because private hospitals pay taxes, contributing to the treasury.

Despite the Taliban's ban on women's education, a few medical institutions also continue to train women in Kabul. However, the fields are limited to midwifery and dentistry.

Both Safi and Amina worry that the limits on what female medical students can study will leave female patients with little help.

"It breaks my heart to see patients suffer simply because there aren't enough medicines, equipment, or female doctors available," Safi said.

Public health facilities across Afghanistan operate mostly with support from United Nattions agencies and other international aid organizations.

Amina said the Taliban-run health ministry pays attention to research reports and donor feedback. She pointed to the authorities' support for vaccination programs.

Still, there is no sign the de facto authorities will lift restrictions on women's education or access to work in health care despite international calls and dissent from within Taliban circles.

Cultural norms coupled with official restrictions mean some of the most vulnerable cannot receive the care they need.

"I hope for a future where health care is accessible to all," Safi said. "And female doctors can work freely without fear or restrictions."