Afghanistan

Afghanistan Annual Appeal No.01.55/2004 Programme Update No. 1

Format
Situation Report
Source
Posted
Originally published

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The Federation's mission is to improve the lives of vulnerable people by mobilising the power of humanity. It is the world's largest humanitarian organisation and its millions of volunteers are active in over 181 countries. For more information: www.ifrc.org
In Brief

Appeal No. 01.55/2004; Programme Update No. 1; Period covered: 1 January to 31 March 2004; Appeal coverage: 31.7%; Outstanding needs: CHF 7,128,981 (USD 5,524,200 or EUR 4,613,778).

Appeal target: CHF 11,090,663 (USD 8,594,082 or EUR 7,180,746)

Programme summary: Forty-four per cent of the appeal funding coverage has been utilised in the implementation of programmes during the first quarter. While the health programme has a total share of 36 percent from the coverage to date, most of the funding is earmarked for basic health centre projects, leaving the community-based first aid and environmental health components with very little to effectively implement their activities. Disaster management and humanitarian values are other areas facing inadequate funding prospects.

Despite the funding challenges, the Afghan Red Crescent Society, supported by the Federation, continued to provide vital healthcare services through its 49 fixed clinics throughout Afghanistan.

As part of the national society's efforts to position its established health activities within the ongoing defined basic package of health services, a survey was conducted so that objective criteria could be utilised in determining the clinics to be closed, those to become social service centres, those to become basic health centres and clinics that would remain in the current society format.

The Afghan Red Crescent Society constitution review process gained momentum. An analysis of the revised constitution has been performed and a comparative new draft has been prepared for discussion. The national society will also formally establish an interim branch membership system whilst it proceeds with work on its new constitution. This is a step in the right direction for the society in becoming a better functioning national society with well defined roles of governance and management and improved procedures, systems and structures.

For further information specifically related to this operation please contact:

1. In Afghanistan: Alhaji Qrabic Izidya, President and Secretary General, ARCS Society; phone +93 702 58 222

2. In Afghanistan: Jamila Ibrohim, Head of Delegation, Afghanistan; email hod.kabuldel@wireless.ifrc.org; phone +873 382 280 530; mobile +93 70 27 83 72; fax +873 382 280 534

3. In Geneva: Jagan Chapagain, Regional Officer; email jagan.chapagain@ifrc.org phone +41 22 730 4316; fax +41 22 733 0395

This Programme Update reflects activities to be implemented over a one-year period. This forms part of, and is based on, longer-term, multi-year planning. (Refer below to access the detailed logframe documents). All International Federation assistance seeks to adhere to the Code of Conduct and is committed to the Humanitarian Charter and Minimum Standards in Disaster Response in delivering assistance to the most vulnerable. For support to or for further information concerning Federation programmes or operations in this or other countries, or for a full description of the national society profile, please access the Federation's website at http://www.ifrc.org.

Operational Developments

The new Afghan national constitution was formally ratified by the country's president in January. The constitution outlines a tolerant, democratic Islamic state under a strong presidency, a two-chamber parliament and an independent judiciary. It also declares men and women equal before the law. It recognises minority languages as the third official language, apart from Pashto and Dari, where these are spoken.

Following the adoption of the new constitution, the disarmament process progressed in earnest. Dozens of mujahideen turned over weapons to the International Security Assistance Force (ISAF) in Kabul. The disarmament programme provides assistance to demobilised militias in the way of money and promises education, farm equipment and jobs. Under the UN sponsored disarmament, demobilisation and reintegration programme, Afghan authorities decided to reduce its military forces by 40 per cent. A total of 3,544 militias were demobilised while 2,127 went through the reintegration process. The defence ministry reported 3,000 soldiers deserted from the newly reconstructed Afghan National Army (ANA). The ANA is currently estimated to have 7,000 personnel.

The first post-Taliban elections have been rescheduled for September 2004, three months later than originally planned. The joint Election Commission and United Nations Assistance Mission for Afghanistan (UNAMA) decided that the delay would enable holding both the presidential and parliamentary elections concurrently. The main reason for the delay has been the inability to reach the target of registering 10 million voters. An encouraging statistic is that 26 per cent of registered voters to date are women.

The previous Special Representative of the UN Secretary General for Afghanistan, who completed his tenure in January, told the UN Security Council that there should be an immediate expansion of the ISAF and stressed the need to convene another international conference to improve and accelerate the performance of the Afghan government and its international partners in implementing the Bonn process. In a related development, the European parliament adopted a report in January considering "it is imperative that neighbouring states, especially Pakistan and Iran, respect Afghanistan's sovereignty, refrain from interfering in Afghanistan's internal affairs and end all support, tacit or otherwise, for any political or armed Afghan faction". It particularly urged Pakistan to take immediate and effective steps to prevent anti-government Afghan formations and leaders, political or military, from using its territory as a sanctuary and as a base for operations against the Afghan government, coalition forces and local development aid workers.

Following a visit by the Pakistan Prime Minister in January, the two countries resolved to strengthen their cooperation in fighting terrorism and enhancing trade and commerce between the two nations.

On the economic front, the forecast growth rate is 30 per cent which illustrates remarkable progress. However this figure needs to be seen in the light of starting from an exceptionally low base. The opening of a major international trading bank in Kabul this year is an example of economic evolution.

Donor nations at the Berlin conference pledged USD 8.2 billion in aid for reconstruction of Afghanistan over a period of three years. This includes the current year's total requirement of USD 4.4 billion.

Afghanistan and its six neighbours - China, Iran, Pakistan, Tajikistan, Turkmenistan and Uzbekistan - signed a regional cooperation accord to step up the fight against narcotics.

Security threats continued to come from a combination of factional fighting, anti-government elements and increased insurgency in the southern region. Coalition operations have continued in Afghanistan and the drug eradication campaign has proceeded.

Despite security concerns affecting humanitarian operations throughout the country and in particular the killing of an Afghanistan Red Crescent Society (ARCS) branch president in March, the national society continued to operate and provide assistance to meet the need of Afghanistan's vulnerable people.

Health and Care

Overall Goal: Vulnerability to health hazards and emergencies in Afghanistan is further reduced.

Programme Objective: To strengthen the capacity of ARCS to contribute to the improvement of the health status of vulnerable people and to respond effectively to disasters through health interventions in Afghanistan.

Basic health centres project objective: To provide healthcare services to the vulnerable people of Afghanistan through ARCS health facilities.

Progress/Achievements

A clinics assessment survey was conducted so that objective criteria could be utilised in determining the clinics to be closed, those to become social service centres (SSCs), those to become basic health centres (BHCs) and clinics that would remain in the current national society format. (Specific criteria for each category are available from the national society and country delegation.) An analysis to identify which clinics meet each category of criteria is in progress. All 49 clinics are still currently operating as per the ARCS format.

The survey is part of ARCS efforts to position its established health activities within the ongoing Ministry of Health defined basic package of health services (BPHS). The process is also to meet the performance-based partnership agreement system (PPA) requirements which is integral to health service reconstruction.

A cost recovery study to be undertaken by Federation consultants will augment the clinic survey. It will also contribute to the ongoing discussions with the Ministry of Health on protocols for the national society's health activities. The study will investigate cost recovery possibilities such as schemes to include community participation in the running of clinics with a focus on vulnerability.

The national society's 49 clinics, supported by the Federation, continue to provide vital health care services. All clinics offer health education, consultation, treatment and provision of essential drugs. Two more clinics were trained and approved by UNICEF to offer expanded programme of immunisation (EPI) services, bringing the total to 42. A total of 35 clinics offer antenatal, postnatal and child growth monitoring services. Family spacing is offered in 32 clinics, and intra-uterine device (IUD) insertion is available in six clinics in the Kabul region.

ARCS provided further training to existing traditional birth attendants (TBAs) with the aim of reduc ing pregnancy and delivery related deaths. The construction of a new clinic in the remote area of Adraskan district in Herat province was completed during the first quarter.

During the first quarter, around 41,000 people attended group health education sessions in ARCS clinics with more than 5,000 people receiving individual health education. A total of 5,000 women attended antenatal consultations while 2,900 attended postnatal consultations. Over 8,000 children attended for growth monitoring. TBAs made over 7,000 home visits to pregnant and lactating women and delivered 2,094 babies.

In addition to routine immunisation, health staff and volunteers were involved in the ongoing polio national immunisation days and measles campaigns where all children under 5 years are targeted.

The national society also participated in a pilot tetanus vaccination programme for women of child bearing age in the highly populated citie s of the country. This year, emergency mobile unit staff and community-based first aid (CBFA) volunteers will attend training provided by the Ministry of Health to participate in pulse immunisation campaigns.

More than 8,000 couples received family spacing advice and supplies. In selected city clinics, trained staff provided IUDs. Due to funding problems, United Nations Population Fund (UNFPA) supplies were not optimal during this quarter and are expected to be even less available in the second quarter.

The table below lists the cumulative figures of attendances and different services rendered to the vulnerable communities during the reporting period.

Categories
January
February
March
Total
Patients seen
56,665
52,437
51,811
160,913
Laboratory tests
3,239
3,372
2,767
9,378
Group heelth Education
50,288
48,609
49,018
147,915
Individual health education
13,325
16,932
11,200
41,457
Antenatal visits
1,912
1,986
2,064
5,962
Postnatal visits
724
1,221
983
2,928
Children growth monitoring
3,004
3,307
2,496
8,807
BCG
3,582
3,032
2,950
9,564
DPT and polio
12,627
9,181
9,061
30,869
DPT polio(3rd dose)
3,966
2,888
2,574
9,428
Measles
3,934
2,887
2,718
9,539
Tetanus (women)
9,231
10,273
9,702
29,206
Family spacing clients
2,576
2,090
3,531
8,197
TBA deliveries
897
444
753
2,094
TBA home visits
3,040
3,516
4,179
7,559

To further compliment rather than duplicate Ministry of Health services, the World Health Organisation (WHO) has been approached to include ARCS clinic staff in the integrated management of childhood illness (IMCI) and the internationally recommended control strategy for TB (DOTS) training. Thus over the next three years the goal is to have all ARCS clinics offering IMCI, DOTS and malaria control programmes in line with BPHS standards.

As part of building the capacity of the national society to deliver quality service, the Federation and ARCS national headquarters staff attend Ministry of Health consultative group meetings on health and nutrition, taskforce meetings on health management information systems (HMIS) and health emergency preparedness and response.

Three three-day workshops were held in Kabul, Jalalabad and Mazar to introduce clinic staff to the new HMIS system and to undertake a review of clinic protocols based on WHO standards. Reproductive health workshops were held in Kandahar, Herat and Mazar. TBA training and refresher training took place in all five sub-delegations during the quarter, including a one-day course for 13 new TBAs held in Mehterlan-Jalalabad. EPI workshops were held in Herat, Mazar and Kabul to prepare ARCS staff and volunteers for effective participation in immunisation programmes.

National society and Federation regional health officers continue regular supervision and mentoring support visits to all clinics - security permitting - and actively encourage branches, particularly through the branch presidents, to become more involved in clinic activities and in all aspects of the integrated primary healthcare programme. CBFA and the health clinics are working more closely in the areas where there is a clinic near CBFA teams of volunteers. Volunteers are also encouraged to make contact with their nearest clinic.

Coordination is a key aspect in all regions. ARCS and Federation health officers attend all health coordination meetings. Normally there is a monthly meeting at the Ministry of Health in all regions, plus other adhoc meetings, chaired by the ministry. The health teams also meet regularly with UN agencies such as UNICEF, and with other NGOs providing health services. ARCS clinic staff are also invited to attend training offered by the Ministry of Health and NGOs. The national society has invited external organisations to attend or cofacilitate training workshops. At the central level there are many taskforce meetings covering issues such as reproductive health, EPI, communicable diseases and health education. National society and Federation senior health staff are involved in many of these taskforces and also attend regular health NGO meetings.

Impact

ARCS clinics in many cases provide the only access to healthcare for vulnerable people. There is confidence in the community that national society clinics will provide consultation by qualified and dedicated doctors and that appropriate drugs will be available free of charge. Health education is one of the most important health activities to advise and teach people how to prevent ill health and when to seek medical attention urgently. There is an increased emphasis on nutritional education in 2004 - crucial in a country where the under-five mortality rate is 257/1,000 live births and stunting from chronic malnutrition is estimated to affect up to 59 per cent of Afghan children (source MOH/UNICEF/CDC 2002).

In a country with a maternal mortality rate of 1,600/100,000 live births and an infant mortality rate of 165/1,000 live births, and where the majority of women deliver with no trained health person in attendance, antenatal attendance and TBA services are vital. When mothers bring their children for growth monitoring they also receive advice on nutrition and other important health messages. Children showing signs of malnutrition are seen by the doctor to treat any medical causes and then referred to nutrition centres where available. With the alarmingly high prevalence of chronic malnutrition, the synergy of monitoring, nutritional education and IMCI initiatives are receiving increasing importance in all ARCS clinics.

Immunisation is one of the most effective preventive measures. Children can be protected from diphtheria, whooping cough, tetanus, polio, measles and tuberculosis. Pregnant women who have received the tetanus vaccine not only protect themselves but also their unborn child. This vaccine is offered to all women of child bearing age. Family spacing impacts positively on the health of those families who are able to space their children, thus ensuring that women have time to recover from one pregnancy before embarking on another. Expansion of EPI to all clinics will ensure the national society makes a greater impact on increasing immunisation coverage. Out of 49 clinics, 42 now offer EPI.

Training workshops for clinic staff and supervision visits are keeping staff updated and motivated, enabling them to offer the best possible service to the client. Similarly, regular liaison, including sharing of ideas, helps to ensure that beneficiaries receive the best possible service from all health agencies and that agencies do not duplicate services.

As CBFA and health teams are beginning to work more closely, greater trust and understanding is slowly building up between volunteers and the clinics. This is improving service delivery to patients referred to clinics by volunteers. The national society is working towards clinics requesting the help of volunteers in following up patients, particularly poor attendees for antenatal clinic s or immunisations.

The establishment of health committees is boosting community participation in health services provided by the national society which will, in the long-run, improve the sustainability of clinics.

Constraints

Funding constraints have meant the implementation of the first phase of the BPHS is focussing on the rural and most under-served areas. As more funding is secured over the three-year period of this programme, other areas will be targeted, with the goal of 70 per cent coverage by the end of three years. Since the majority of ARCS clinics are located in urban areas, at least for the initial phase of BPHS, these services may provide the only access to medical care for many of the communities in which they exist. A recently completed ARCS/Federation survey of national society clinics has identified clinics that may be redundant to Ministry of Health facilities when the BPHS is implemented. There is a plan to change some facilities into SSCs for training and volunteer recruitment. Ten facilities were identified as being able to downgrade services to meet the standards of a BHC under the BPHS. As PPAs are signed and implemented in areas where these clinics have been identified, one of the above three options will be put in place. However in the first quarter of 2004, no PPA was fully implemented in any area where ARCS clinics are located, thus all 49 clinics are still in operation under national society format. .

Although many women are now attending antenatal support and advice, postnatal attendance remains low. Clinic staff have been urged to stress the importance of postnatal attendance during their antenatal visits.

Organisations working in Afghanistan are highly dependent on UNFPA which provides all safe birth and reproductive health kits. However in March the UNFPA informed all organisations with orders pending (promised delivery date of January 2004) that it would only be able to deliver 20 per cent of requirements due to underfunding. While family spacing is a relatively new concept in Afghanistan, the scarcity of reproductive health items would erode confidence in the national society's services to the clinic's female catchment population. Other constraints include the lack of qualified female staff in general and, in particular, offering these services in all clinics. A proactive recruitment drive, with transportation provided, has had some success in attracting the appropriate staff, but like the Ministry of Health, all health facilities continue to have difficulties meeting these needs because of the cultural sensibilities of the Afghan population.

Recognising the importance of regular supervision and follow-up of TBAs after training, there is still a need for well qualified midwives to train as TBA supervisors, especially in rural areas. The national society is actively seeking more qualified female staff.

Most children in clinic catchment areas are receiving vaccinations. However many areas are still not covered by clinics and it is difficult for children in these parts of the country to receive routine vaccinations. In Kandahar and Herat the mobile teams are discussing with the Ministry of Health and UNICEF to try to establish a cold chain so that they can take the immunisation programme to remote areas. For malnourished children there are referral centres in most regional capitals. However, there is still a problem for malnourished children in more remote areas where it is also difficult to find qualified staff.

Due to security constraints, many provinces have been off limits to all Federation staff, making it very difficult for on-site supervision and training. ARCS health officers have made some visits but, due to staff turnover and shortages in some regions, along with the security constraints, this activity has slowed down considerably over recent months.

Emergency mobile units project objective: To respond to disasters and emergencies through mobile medical units in coordination with the ARCS disaster response unit and in close collaboration with other partners, and also provide community outreach services to under-served communities.

Progress/Achievements

An emergency mobile unit (EMU) training-of-trainers (ToT) course, facilitated by Norwegian and Finnish emergency response delegates, was held in March with ten participants from around the country. Most of these were ARCS regional health officers. The facilitators also conducted refresher training for the Mazar EMU team members.

The Herat mobile teams travelled to Iran in early January to take part in the response to the Bam earthquake in a cross-border operation between the two sister societies. Upon their return to Afghanistan, they responded to the flood in Injeel district. The mobile teams from Kabul, Kandahar, Mazar and Jalalabad all provided services to their respective districts/cities.

During the first quarter, the mobile teams treated 11,700 patients in remote areas without access to primary healthcare facilities. Most of these people also received health education in groups or individually. Tabulated figures below show the monthly attendance breakdown.

Services Provided
Month
January
February
March
Total
EMU activities
Patients seen
3,441
3,082
5,177
11,700

Presently there are two teams in each of Kandahar, Mazar and Herat, one team in Kabul and one in Jalalabad. As mentioned in the previous section, the Kandahar and Herat sub-delegations are also working with the Ministry of Health and UNICEF to try to set up a cold chain to offer outreach vaccinations to remote areas. Due to security problems, the teams could not visit the villages regularly, especially in the Kandahar region. In addition to the health services provision in the villages, the mobile teams actively took part in national immunisation days for polio eradication and TB vaccination campaigns.

During the opening quarter, 706 new CBFA volunteers were trained in 212 villages, many of which receive care from the emergency health teams. The close link between the two programmes involves social mobilisation of villagers for national immunisation days and clinical visits to remote areas.

The health department has coordinated regularly with the emergency preparedness and response director of the Ministry of Health. Regular coordination with the WHO and Ministry of Health has taken place regarding possible disease outbreaks in various parts of the country.

Impact

The EMU ToT course will contribute to the sustainability of the project with a pool of local trainers and a reduction in reliance on external expertise, as well as ensuring ongoing capacity building. The contribution of the EMU teams in response to the health emergencies is gradually being increased, which in turn is improving the lives of vulnerable people and addressing urgent cases. EMU activities also raise the profile of the national society in the field.

The mobile teams bring much needed health support to remote areas where there are no other health facilities. The new volunteers and mobile teams have a good rapport which is contributing to improving the service delivered to beneficiaries.

Constraints

Security has been a major constraint, especially for the deployment of the EMUs to some of the more needy areas. Other constraints have been the loss of some key staff, mainly for financial reasons. The national society has instituted a hardship allowance which will hopefully decrease turnover.

Environmental health project objective: To supply clean water to vulnerable populations and increase the availability of sanitation facilities and hygiene promotion, integrated with the community-based health and DM programmes.

Progress/Achievements

Progress in the first quarter has been very encouraging despite various constraints. Much has been achieved in trying to supply people with clean water from newly rehabilitated and constructed wells. A total of 45 wells were rehabilitated and 52 new wells were constructed, bringing the cumulative total to 97 wells. Below is the table indicating the breakdown between Kandahar and Herat.

Period
Province
Rehab.
New wells
Total
January
Kandahar
10
10
Herat
20
15
45
February
Kandahar
9
54
Herat
25
79
March
Herat
10
83
Kandahar
14
97
Total
97

The programme is on course to achieve the target of 220 wells to be constructed this year. The rehabilitated and newly constructed wells will cover a total of 13,350 people. The government regulation is that one well covers 25 families with an average of six people. The wells being constructed by the national society/Federation follow the government policy which came into effect in December 2003.

The hygiene promotion continued on from last year with a few changes in the approach so that more people can benefit from the ongoing activities with volunteers from CBFA. A baseline survey was conducted in Herat and the indications are that there is a gap in information on hygiene. Communities have shown a willingness to participate in the programme. Hygiene promotion in Kandahar is quite advanced despite security issues restricting the team to the city limits. Kandahar has two hygiene trainers in the programme and they have continued to monitor the volunteers recruited and trained last year. Over 10,000 people collectively in Herat and Kandahar have received hygiene education sessions in the first quarter.

A workshop was conducted in Herat for 20 female branch volunteers to be involved in the hygiene promotion programme. The volunteers will be responsible for hygiene promotion in the areas of operation and also train community volunteers who will conduct house-to-house hygiene promotion in their respective areas.

It was planned to support the community-based construction of 170 family latrines in Herat (100) and Kandahar (70) during the first quarter. Progress has been made with the distribution of 104 latrine slabs in Kandahar district five. A production site was commissioned in a district in Herat province for the latrine slabs, and community meetings were held where the modalities of programme implementation were discussed and agreed upon. The most significant output from the meetings was the overwhelmin g response from the communities to participate in the project and they further agreed to contribute materials. The construction of 100 family latrines is underway.

Impact

There has been a reduction in cases of waterborne diseases, with a considerable reduction in diarrhoeal cases. Water sources have been created closer to communities making it easier for them to source clean water. There has been positive feedback from communities who have to date not been involved in the programme, requesting health and hygiene education. This is evidence of greater awareness in communities of the importance of this knowledge.

The use of female volunteers is gaining greater acceptance in rural communities. In some cases, female volunteers are holding public hygiene promotion sessions where men are quite happy to receive instruction from a woman, which is significant in the cultural context of Afghanistan.

In Kandahar there has been significant improvement in the disposal of human waste as well as the cleanliness of the surroundings of targeted communities.

Constraints

The two main constraints for the programme are security and funding. Security has been the major concern especially for Kandahar, where activities have been reduced to the city limits. Lack of funding is also threatening this key element of the health programme, and this needs to be addressed as a matter of urgency to ensure the ongoing implementation of the planned activities.

Community-based first aid project objective: To deliver preventive health services such as first aid, health education, HIV awareness, participation in immunisation campaigns - particularly in rural communities - through community-based volunteers linked to branches and health centres; further to continue to provide timely responses to disasters and disease outbreaks.

Progress/Achievements

After completion of the reorganisation of trained CBFA volunteers in the central and eastern regions during the past year, the focus has shifted to the western and northern areas. Following an assessment in 11 areas, 67 courses were organised for previously trained volunteers in the Herat region and 64 courses in the Mazar region. Volunteers were organised into town or village community groups composed of five members, with each having a responsibility for activities in each project core area.

The programme is active in 23 of the 33 provinces of Afghanistan and has been expanded to include the Farah and Jawzjan provinces of the western and northern regions respectively. Training has already commenced Farah.

The training programme for new volunteers is ongoing in provinces where the programme is already established. During the first quarter, a total of 706 new volunteers covering 212 villages (comprising of 599 male and 107 female volunteers) have been trained. This brings the total number of CBFA volunteers to 16,528 across the country, organised in 778 groups in 164 districts, covering 13,621 villages of the 23 provinces. Most of the trained volunteers have received first aid materials after a long absence of these recourses.

Over 10,000 volunteers were targeted by team leaders and trainers for follow-up sessions. To date, nearly 7,000 have participated in these sessions. These active volunteers have provided first aid or advice to almost 82,000 people and provided health education and mine and disaster awareness to over 132,000 individuals.

In an effort to increase sustainability, the CBFA staff and volunteers endeavour to mobilise communities to contribute towards supporting the group of volunteers in their localities. The goal this year is to double the current number of 71 such corners though no progress was made in the first quarter.

The CBFA volunteers have commenced spreading awareness messages on HIV/AIDS in their respective areas. They are disseminating simple messages on ways of transmission, signs and symptoms and prevention in order to sensitise and familiarise the community on HIV/AIDS.

Impact

With the team approach, the profile and visibility of volunteers is on the rise in the covered areas which is improving the scope for passing health messages. The continued provision of timely first aid, coupled with relevant health messages, will in the long-term contribute to increasing the coping capacities of the vulnerable in the community.

Communities are placing more trust in volunteers. This is resulting in the public more readily utilising the community corners to access first aid or health advice. This in turn is leading to offers of resources such as dressings and supportive activities from members of the public.

Remote communities are benefiting from the health education activities of CBFA volunteers, gaining knowledge and the capacity to protect themselves from common preventable diseases and conditions such diarrhoea and malaria. There has also been a heightened awareness of the importance and benefits of immunisation for children and mothers. Communities have received timely first aid for basic injuries/illnesses. Mine awareness education is proving valuable for a country that has been caught up in armed conflict for the past quarter century.

Female volunteers are having a significant impact as they are able to reach the women in their families and share health messages on topics ranging from mother and child health to reproductive health. It is also notable that female volunteers are taking a more proactive role and are able to deliver health education to men in some instances.

Knowledge of HIV/AIDS is totally unknown in some areas with low literacy rates. Dissemination work of volunteers is chipping away at this mountain of ignorance.

Constraints

Instability, poor roads, an insecure working environment, high transportation costs, and a lack of adequate funding for follow up of activities are the major constraints. Trainers cannot reach all team leaders monthly nor conduct group meetings with all trained volunteers. Provision of dressing material for refilling of volunteers' first aid kits has also been slowed down and some provinces, such as Herat, did not have dressing material until February.

Security (robbery, armed theft and anti-government elements) is an additional burden for communities which are already affected by unemployment and poverty. Many of the more able community members, who could have assisted volunteers on the way to self-sustainability, have left, and thus mobilising local resources to ensure sustainability and improve coping mechanisms remains a slow and difficult process.

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