JANN

日本アフガンNGOネットワーク

Japan Afghan NGO Network

JANN Afghanistan Briefing Pack

 

Section 3. Aid Environment

 

 

 

3.1 Aid Process Overview

(This section is taken from: AREU 'A-Z Guide' August 2005)

NDF - National Development Framework

The National Development Framework (NDF) was drawn up by the government as a road map for the development and reconstruction process in Afghanistan. It details sixteen national sectors under three broad pillars, and identifies six cross-cutting issues. The first draft of the NDF was made available to the public in April 2002, and although some slight adjustments have been made to it the NDF remains the primary basis for government and donor planning. The Ministry of Finance is responsible for overseeing the implementation of the NDF.

Each of the sixteen sectors identified in the NDF are considered National Development Programmes (NDPs) and are overseen by a corresponding Consultative Group (CG). These sixteen CGs operate as a forum within which the details of reconstruction and development projects in each sector can be designed and discussed. Each CG then implements its sector's plans by proposing a Public Investment Programme (PIP) for the National Development Budget (NDB).

The original NDF identified six National Priority Programmes (NPPs) that were to take precedence over other activities, and in April 2004 President Karzai announced the creation of six additional priority programmes. These programmes were known collectively as the NPPs and were meant to be major policy priorities for the government. However, most NPPs have since been incorporated into the NDP with which they were most closely linked.

 

Pillar I - Human Capital and Social Protection	Pillar II - Physical Infrastructure	Pillar III - Enabling Environment for Development	Cross-Cutting Issues
•  Refugees and IDPs •  Education and Vocational Training •  Health and Nutrition •  Livelihoods and Social Protection Culture, Media and Sport	•  Transport •  Energy, Mining and Telecoms •  Natural Resource Management •  Urban Management	•  Trade and Investment •  Public Administration and Economic Management •  Justice •  National Police, Law Enforcement and Stabilisation • Afghan National Army •  Mine Action • Disarmament, Demobilisation and Reintegration	•  Gender • Environment •Humanitarian Affairs •  Human Rights •  Monitoring and Evaluation •  Counter Narcotics

 

NDS − National Development Strategy

(see: www.afgnds.gov.af )

The Afghanistan National Development Strategy (ANDS) was first publicly proposed at the Afghanistan Development Forum (ADF) in April 2005. The overall vision of the ANDS is to promote growth, generate wealth and reduce poverty and vulnerability. Until the ANDS is established, the National Development Framework (NDF) of April 2002 and the government's Securing Afghanistan's Future report of March 2004 continue to guide government policies and allocation of resources for development and reconstruction. However, the NDF and Securing Afghanistan were prepared quickly with hasty consultations, and this resulted in a lack of awareness of these efforts and limited implementation of their recommendations.

The ANDS will be informed by careful consultation with representatives at all levels of the government, the private sector, NGOs, civil society and the international community. An ANDS Working Group, under the guidance of an inter-ministerial Oversight Committee, has been formed to lead the consultation and drafting processes. The ANDS will be structured into eight pillars: Infrastructure and natural resources; Agricultural and rural development; Human capital and gender equity; Social protection; Economic governance and private sector development; International and regional cooperation; Good governance and rule of law; and Security.

Each pillar will have a working group that includes representatives from central and provincial government, donors, the UN, NGOs and civil society, as well as technical experts. The timeline for completing the first ANDS draft is September 2005. It is expected that this draft will be finalised and approved by the government by December 2005 or January 2006, corresponding with a major donor meeting planned for the same time in London. The ANDS will serve as an Interim Poverty Reduction Strategy Paper (PRSP) for the Afghan government.

 

3.2 Refugees and Internally Displaced People

(Reiko Hirai - PWJ)

As a result of the 1979-1989 Soviet invasion and the ensuing drawn-out civil war, as well as drought and other reasons, large numbers of Afghan people have been forced to live as refugees both overseas and within Afghanistan. At its peak, the number of Afghan refugees who had fled the country was estimated at 5-6 million people, and the number of IDPs (internally displaced people) was thought to be between 1.1 and 1.5 million people. At that time, Afghanistan was labeled the world's largest refugee crisis.

Following the fall of the Taliban regime (in the wake of American air-raids after September 11 th 2001), and the subsequent establishment of the Afghanistan Interim Administration in January 2002, many refugees and IDPs started to return home. Between March 2002 and February 2005, it is estimated that 3.5 million refugees (2.3 million from Pakistan and 1.2 million from Iran) and 500,000 IDPs have voluntarily returned home. However, although the message is put out that conditions for return are favourable, at the same time, the fact that the security situation is bad in many parts of the country and that there are few prospects for establishing new livelihoods after returning home remains a key inhibiting factor to potential returnees. It is estimated that there are still 18.5 million refugees continuing to live in Pakistan, and 800,000 in Iran. It is now feared that Pakistan and Iran may cut aid to refugees, and that refugees will be to an extent forced to return home. Meanwhile, an estimated 180,000 IDPs − mainly in the south and west − are compelled to live as refugees.

In the areas where refugees and IDPs have already returned home, the security situation, drought, lack of employment opportunities, and problems of access to agricultural land are causing serious impediments to the rebuilding of livelihoods. In urban areas such as Kabul, where the there are concentrated numbers of returnees, it is feared that the living environment will worsen as a result of the population increase. It is necessary for the Afghan government and the international community to make a long-term commitment to rebuild the lives those who have already returned and those who will return in the future.

 

3.3 Health Sector

(Hiroshi Taniyama - JVC)

Within the Afghanistan reconstruction process, the health sector is seen as one of the most important sectors from the point of view of peoples' needs, government policy, and also international aid objectives. The health situation in Afghanistan is highly inadequate, and ranks amongst the worst in the world. This is the partially the result of 23 years of consecutive civil war, but even before the war, the system did not provide services to remote regions.

According to a six-month survey carried out by the government in 2002, one third of the medical and health facilities surveyed across the country were damaged in some way. Most of this damage was the result of the war. On average, there is one medical or health facility for every 27,232 people nationwide. But these figures vary considerably from region to region: in Faryab, Ghazni, Ghor and Uruzgan provinces, there is one facility for every 40,000 people. In the worst case, there is one facility shared amongst 5 districts − a total of 100,000 people.

The poor state of medical services has the most serious impact on women and children. According to a government report in 2004, infant mortality for babies under 1 year of age was 165 in every 1000 children (compared to 4 per 1000 in Japan). Infant mortality for children up to the age of 5 was 257 per 1000. The maternal mortality rate was extremely high at 1,600 in every 100,000 (compared to 6.5 per 100,000 in Japan).There are a number of prevalent illnesses such as diarrhea, bronchitis, tetanus, malaria, polio, tuberculosis and so on. But the key point to note is that there are so many children who die from dehydration caused by diarrhea, and so many mothers who die from tetanus picked up whilst giving birth.

A further problem relates specifically to female patients. Afghan traditional culture imposes limits upon how much women can leave the house, and prohibits women from coming into physical contact with men who are not their immediate relatives. As a result, there are many cases when even though there has been a doctor, it is difficult for a female patient to visit him and receive treatment. If a woman is having problems giving birth and there is no female doctor or midwife available, it is not possible to receive any treatment. Furthermore, the number of female medical practitioners is less than one third the number of male medical practitioners, and the ratio becomes even more unbalanced in rural areas. In Nuristan province the ratio is 1 female to every 60 males.

In remote areas, access to medical facilities is extremely bad, but even in cases where patients do access their nearest facility, on many occasions they are unable to receive adequate treatment because of a shortage of staff, equipment or medicines. Only 2% of patients are able to travel to find better treatment − either because of the poor condition of the roads, or because they are unable to pay the transport costs. This is one example of how the state of livelihoods and infrastructure reflects on medical issues.

The 2004 Afghan government policy position paper, ‘Health and Nutrition Public Investment Program (PIP)', lays out a ‘Basic Package for Health Service', which aims to provide medical services that are evenly distributed across the country. The following key aims are set out.

•  To reduce the infant mortality and child mortality rate (children under 5). To this end, to expand the vaccination program, and reduce the number of cases of diarrhea and acute bronchitis.

•    To reduce maternal mortality. To this end, to train female medical practitioners (especially midwives), and dispatch them to work in regional areas. Also, to create an emergency obstetrics centre in each area.

•  To put a stop to the rise of diseases associated with hunger and malnutrition.

•  To adopt policies against infectious diseases such as tuberculosis and malaria.

As for who is actually providing medical services, 47.3% of services are provided by NGOs operating alone, and 27% are provided by NGOs operating in partnership with the government. The large role played by NGOs in the health sector is a point of concern. The Afghan Ministry of Health acknowledges the importance of NGOs, but it has taken two key steps towards bringing NGOs under closer government control. It has made it compulsory for all health agencies to observe the stipulations of the BPHS (mentioned above), which pledges to deliver health services equally across the country. Furthermore, it has adopted a system whereby in every province or district cluster, one particular NGO is entrusted to supervise the delivery of all health services in that area. These contracts are termed “Performance Based Partnership Agreements (PPAs)”. However, this system of contracting out the services is being led by the donors − World Bank, EU and USAID − and it is they who hold the power over NGO bids.

Hence in this system, it is not a case of NGOs supporting government-run clinics (“contracting in”), but rather the NGOs are directly responsible for providing the services. It is said that this system was brought in after it had proved to be comparatively effective when tested in Cambodia. However, it is true that there remain questions as to the sustainability of such a system. The NGOs receive 30-month contracts from the international donors to take overall responsibility for managing the clinics, as well as administering staff salaries. However, there is no guarantee that after the contracts end and the government takes over control, the staff will be paid the same salary as that which they had received from the NGO. (For example, in the PIP annual budget, 1-1.5%of GDP is earmarked, but in 2015 as much as 50% of annual revenue will need to be sought in aid from international donors). Furthermore, even if specific regions are entrusted to particular NGOs, there is still a danger that clinics might fall into a state of functional paralysis if long-established NGOs are at the same time rejected.

Community health is a further key issue in Afghanistan, where large numbers of people do not have access to clinics. In particular, this issue relates to mother and child health. According to a 2003 UNICEF survey, 8% of births are attended by a qualified doctor, midwife or nurse; 8.8% of births are attended by a traditional birth assistant (TBA); and the remainder of births are attended by relatives or friends. Thus far, the Afghan government and NGOs have attempted to lower the rates of maternal and infant mortality in each region by enlisting traditional midwives (TBAs). Except for certain rare cases, in Afghanistan there has been no such thing as a Community Health Worker (CHW).

However, over the past few years, following the advice of the WHO and others, the Ministry of Health has introduced a key policy of training new CHWs, instead of TBAs. The training of these CHWs has all been entrusted to NGOs through PPAs. Following this policy change, NGOs who previously provided training for TBAs are stopping their activities, and instead they have started afresh with the training of CHWs − a concept which does not exist historically in Afghanistan. There have been some complaints that it might not be suitable to train CHWs through a top-down system when the CHWs themselves ought to be firmly rooted in their separate regions. And even if the training of CHWs is indeed successful, it is thought that it would take 10 years for them to become established in the regions. In that time, it is likely that the TBAs who have been trained thus far would fade away through lack of support.

With the policies of contracting out PPAs and training CHWs, Afghanistan's current health policy shows a tendency to introduce ideas from outside whilst ignoring the realities on the ground. At the same time as trying to improve the quality of aid through importing international experience, it is equally necessary to try to use methods that are appropriate for the reality on the ground in Afghanistan. It could be argued that NGOs should not only concentrate on implementing projects, but that they should also engage in policy advocacy towards policies that reflect experience and knowledge gained at ground level.

 

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