Afghanistan

Afghanistan Appeal No. 01.55/2004

Format
Appeal
Source
Posted
Originally published


The International Federation's mission is to improve the lives of vulnerable people by mobilising the power of humanity. The Federation is the world's largest humanitarian organisation, and its millions of volunteers are active in over 180 countries. All international assistance to support vulnerable communities seeks to adhere to the Code of Conduct and the Humanitarian Charter and Minimum Standards in Disaster Response, according to the SPHERE Project.
This document reflects a range of programmes and activities to be implemented in 2004, and the related funding requirements. These are based upon the broader, multi-year framework of the Federation's Project Planning Process (PPP). The PPP products can be requested through the respective regional department. For further information concerning programmes or operations in this or other countries or regions, please also access the Federation website at http://www.ifrc.org

Programme title
2004 in CHF
Strengthening the National Society
Health and Care
6,436,581
Disaster Management
1,749,292
Humanitarian Values
867,682
Organisational Development.
2,037,108
Total
11,090,6631

National Context

The Afghan people are living through a critical stage in the country's development -- the transition from conflict to peace. Real gains are being made by the Afghan Transitional Authority and its partners, but threats to peace remain and a descent into further widespread fighting cannot be ruled out. The success of the rehabilitation and nation building process will decide the future for 26 million Afghans and have a great influence on the wider region.

Afghanistan remains one of the poorest and least developed countries in the world. In human terms this translates into 25 per cent of children dying before their fifth birthday and new casualties every day from mines, hunger and preventable diseases. However, in the face of huge challenges, people are striving for a better life for themselves and their families; the thirst for education and the readiness to rebuild are astonishing.

Nation building is moving ahead with progress towards a new constitution, due to be finalised in 2003, and national elections scheduled for 2004. Efforts are being made to build the judiciary, police and, in tandem with a demobilisation process, a national army. Some of the wounds and divisions in Afghan society are beginning to heal.

Reflecting the shift from an emergency to a rehabilitation context, the humanitarian community is reassessing its objectives and approach. Relief input, though still important, is increasingly are being replaced by more developmental, capacity building approaches. The International Red Cross Red Crescent Movement, working as it does in support of an indigenous national Red Crescent society, is well placed to develop effective responses to emerging needs in a sustainable and strategic way.

The Afghan Red Crescent Society (ARCS), with the support of the Federation and the rest of the Movement, assisted millions of vulnerable people through the worst years of the conflict and will have a unique role in the country's future.

With the increasing focus on capacity development, the ARCS/Federation recently carried out assessments of ARCS branch and headquarters structures -- an essential step to identify strengths and weaknesses and to see where improvement is needed. The society also organised a national meeting, with representatives from all provinces and departments, to define a vision and mission for the coming years.

This important, consultative process yielded further insights into the direction of the national society. Close ties exist between ARCS and the government and, like other organisations, it functions in a policy framework developed by government. Far reaching changes in policy and strategy in key sectors such as health are in hand now. The Movement is working to help shape these changes (through participation in key committees) and also to define how to respond to changing policies - redefining service delivery programmes to meet new realities. The health clinic programme in particular is under review to develop a roadmap for ARCS health services in a post-conflict context where government is contracting the provision of a basic package of health services to different agencies in different geographical areas.

Decades of power struggles and conflict have inevitably taken a toll on the national society but it survives with substantial capacity intact as well as high recognition and the goodwill of millions of Afghans. To some extent this survival story is due to the continuous support from the rest of the Movement. Examples of Federation support since 1991 are:

  • Building national society programme capacity and maintaining awareness of its specific role as a champion of humanitarian values.

  • Providing resources for curative and preventive health services to millions of vulnerable people -- particularly mothers and children using the ARCS' nationwide network of clinics. The ARCS also takes part in national immunisation initiatives -- efforts that have protected 5.8 million children from polio.

  • Building of disaster response capacity in the society through coaching, training and physical resources such as warehouse capacity and vehicles. The response capacity has been shown repeatedly -- from the frequent seasonal floods that affect parts of the country to the Nahrin earthquake disaster in 2002. Rapid notification and response, combined with effective coordination with other actors, make this an increasingly effective programme.

  • Coordinating and helping to attract international donor support to maintain ongoing programmes and also to respond to emergencies such as the post-September 11 operations, where ARCS took a central role in the wider, regional Movement response.

  • Drawing the ARCS into policy debates, agency coordination fora and collaborative ventures with other actors, as part of an overall push towards raising their profile and increasing representation skills; also directly representing the national society on the international stage when necessary.

Red Cross Red Crescent Priorities

Movement context

The Afghan Red Crescent, like any national society, contributes to and benefits from the Red Cross Red Crescent (RCRC) network. In particular ARCS is involved in the many regional initiatives facilitated or coordinated by the South Asia regional delegation, based in Delhi. The most recent regional secretaries general meeting was hosted by ARCS and sessions saw progress and consensus on a range of common issues, such as strategy development, human resource management, constitutional and legal bases as well as debate on other key challenges.

The regional forum is proving particularly powerful in promoting shared learning, common understanding and effective coordination. The Federation, having recognised this potential, is instituting a strategy for change that delegates secretariat management authority and many administrative functions to the regional level. One effect of this is that individual national societies are closer to and becoming more involved in the decisions that affect them.

One of the benefits of this approach is improvements in regional ties between sister national societies. In turn this leads to opportunities for joint training, exchanges, regional disaster response and similar initiatives that reduce costs, improve response and build unity. The society's disaster management personnel have thus benefitted from training in Nepal while dissemination personnel from the region have attended humanitarian values training in Kabul.

Both the Federation and ICRC have been reviewing their programmes in Afghanistan in the light of developments that can be both rapid and contradictory. The security context in particular makes strategic planning problematic, with progress, then setbacks and uncertainty. At the same time it is necessary to take account of government and donor policies that are increasingly developmental in nature.

The Federation is seeking to increase its capacity building engagements with the national society - strengthening management and programming at the central level, but focusing also on delivery capacity and sustainability in the provincial branches. The Federation delegation promotes the aspect of volunteerism in the national society and is also working with ARCS on membership and other ways of grounding Red Crescent services and identity in the communities they serve.

Also, as part of capacity building, the delegation works to empower the ARCS in self-assessment, visioning and planning -- building its own identity, determining programme priorities and finding solutions to the many difficulties that Afghanistan presents those working in the country.

Several partner national societies have been contributing to reconstruction efforts independently of the Federation, but often working with ICRC and, to a lesser extent, with the ARCS. Their activities are summarised as follows:

Red Cross Partners -- Activities in 2003
America
American Red Cross are active in funding water, hygiene and health education, targeting women and children; involvement of the ARCS is minimal.
Australia
Australian Red Cross support work in Herat City, with a focus on environmental health, with some ARCS input.
Britain
British Red Cross main involvement is via ICRC, providing funding and personnel for the rehabilitation of the water supply in Kabul.
Denmark
Danish Red Cross' focus is on Ghazni where it supports the reconstruction and management of health facilities, facilitated by ICRC with some ARCS input.
Finland
Finnish Red Cross supports the reconstruction and management of district hospitals in Samangan and Shiberghan with occasional collaboration of ARCS.
Germany
German Red Cross supports the Marastoon (shelter and training for the destitute) project for ICRC, in close collaboration with ARCS.
Japan
Japanese Red Cross funds work in Taloqan and Kunduz, also in health service reconstruction and staff training, working closely with ICRC.
Norway
Norwegian Red Cross is active in health reconstruction in Kabul, working partly with Kuwait Red Crescent.
Spain
Spanish Red Cross is active in water supply and sewage systems in Kabul.
Sweden/
The Swiss and Swedish Red Cross Societies work jointly in support of
Switzerland
initiatives for hygiene, health and humanitarian values, in collaboration with ICRC.

In many fields, such as tracing, food-for-work projects and support to shelters for the destitute, the ICRC works in support of ARCS capacity (with input from the Federation, which has the lead role in this field). However, ICRC also has priorities in programme areas which it implements in its own right;
  • Promotion of international humanitarian law (IHL) and the Fundamental Principles of the Movement to various specific audiences;

  • Protection of civilian populations and those detained in connection with conflict; visiting places of detention and maintaining dialogue with different factions involved in conflict; and

  • Urban water supply, habitat systems, specialist health services (with inputs from partner societies, including delegated projects).

Both the ICRC and Federation delegations maintain memoranda of understanding (MoUs) with the ARCS regarding their respective roles and responsibilities in Afghanistan, which serves to ensure efficient use of resources through cooperation and coordination among the different components of the Movement. In the same way, signed agreements provide a framework for the relations between the ICRC and the Federation -- standard practice in complex emergency situations such as Afghanistan.

National society strategy and programme priorities

The Afghan Red Crescent does not have a current strategic plan, however the choice of strategic directions is increasingly on the agenda. This is due in part to a series of Federation-supported reviews and assessments during 2002 and 2003. Development of a strategic plan is now a priority and this will in due course lead to development of a cooperation agreement strategy (CAS).

In 2002 a branch assessment was carried out by the ARCS with Federation and ICRC participation. Each of the 31 branches was visited by an assessment team and standard information gathered through observations and interviews. Although good performance was noted in many areas there were consistent weaknesses identified - human resource (HR) systems, knowledge and application of systems, understanding of the fundamental principles, connection with local communities and basic functional facilities. Altogether the picture is of branches trying hard to deliver services but with inadequate resources and support.

A review of the national headquarters was undertaken by a consultant in 2003. Separation of governance from management was identified as a priority, though a functioning membership system is a prerequisite. Other key issues included better and structured communication with branches, delegation of branch HR to the local level, raising ARCS' profile both nationally and internationally, and standardisation of reporting systems.

Health and organisational development (OD) programmes were also assessed in 2003, by technical department heads from Geneva. Service provision to vulnerable and remote areas was seen as an issue for greater prioritisation, along with standardisation of the services offered by clinics. The overall positioning of ARCS in the health sector was also queried. In OD, a more bottom-up approach to planning was proposed, as was reduced Federation input to traditional OD, in favour of capacity building through programmes.

A national 'visioning' workshop was held in 2003, with the participation of all branches and departments and produced the following vision:

"ARCS is a national society in which the activities are performed on the basis of the Fundamental Principles of the RCRC Movement and the statutes of the national society. Membership systems, volunteers' networks and the financial base of the national society are improved. The national society receives support from the government and the international community and is able to respond to the needs of the most vulnerable people affected by natural or human made disasters through its programmes in the national headquarters and branches. Staff have received proper training and work is given to employees on the basis of professional ability. Attention is paid to the public health, especially of women and children. The national society has good relations with the components of the RCRC Movement, sister national societies, and national and international organisations."

One analysis of this process and its outputs was that ARCS at all levels needs to gain better understanding of the Movement - the range of activities that define a national society, the auxiliary role, the focus on the most vulnerable. Participation in regional networking is seen as one way to address these shortcomings.

The ARCS, with growing awareness of the need to adapt its structure and systems to the Movement standards, has in 2003 embarked on the process of reviewing its dormant constitution. Once implemented, in 2004, it will enable the national society to define the roles of governance and management and prompt further democratisation, including clear policies and a diverse membership base.

Similar efforts in developing a three to five year national society development plan will, in 2004, ensure a clear strategy and ensure that ARCS does not miss the opportunity to become a visible player in the nation building process. It will also demonstrate more effectively the added value and ARCS' unique role as an auxiliary to public authorities in meeting the humanitarian challenge facing the country. The ARCS strategic mapping will bring a better understanding of community needs, its own capacity to respond as well as the resources available internationally to assist activities. This will be complemented and reinforced through the Federation's CAS mechanism, a key tool in the Federation's efforts to coordinate the programming of various partners.

Strengthening the National Society

Over many years substantial investment has been made in building the capacity of the Afghan Red Crescent; its continued nationwide presence and delivery of vital services is a testament to the success of these efforts. However the national society has also been buffeted by the conflict -- both military and political -- that has dominated the country's recent history. This, together with the chronic poverty which the nation endures, has greatly hindered the development of a better functioning organisation. The ARCS remains in need of infrastructure, stronger human resources, better systems and local income sources. A simple SWOT analysis of ARCS reveals both the potential and the obstacles it faces.

Internal
External
Strengths
- Indigenous, national organisation
- Long experience
- International Red Cross and Red Crescent Movement support
- Symbol of neutrality, public recognition.
- Participation in regional fora.
- Experience in health and relief.
- Willingness to change.
Opportunities
- International interest and commitment.
- Movement support and strong Federation and ICRC presence
- Improvements in the economic, social and political environment.
- Developing national context in which ARCS could secure a key role.
- Better links with relevant ministries and departments being forged.
- Engaging Afghans returning from abroad in nation building activities.
Weaknesses
- Frequent leadership and staff changes.
- Poor institutional memory.
- Governance system is weak and statutes are not respected.
- Insufficient trained human resources, particularly volunteers and youth.
- Lack of sustainability and diversity in income sources.
- Links between headquarters and branches are inadequate.
Threats
- Renewed instability leads to a lack of progress to development and donor fatigue.
- New displacement and upheaval.
- Public frustration at slow rate of progress.
- Future governments abuse the independence of ARCS.
- Further natural disasters, such as drought and earthquake.

The internal vision for ARCS, defined and adopted with representatives of all 31 branches, supports the picture of the SWOT -- great aspirations, significant potential and major challenges. Health programming remains a central component of the activity of ARCS, but also shapes its identity.

The primary health care clinics have served an important humanitarian role and helped to maintain the profile of ARCS across the country. Health education and preventive services have been strengthened and further progress towards community health models of activity is foreseen, community-based first aid (CBFA) being perhaps the most promising model.

Disaster management work has progressed during 2003 and ARCS is better positioned than ever for effective response activities. The introduction of a community-based disaster preparedness (CBDP) component in 2004 will enhance the preparedness aspect of the disaster management equation while building links between branches and their communities and generating a stronger volunteer base.

There still remains much work to be done on recruiting volunteers and on involving youth in the organisation. To date most youth projects have tended to target young people as beneficiaries; the challenge for 2004 is to begin facilitating their role as deliverers of services to their communities. The humanitarian values, CBDP and CBFA programmes all present opportunities for developing a more active youth element in the ARCS.

Additionally the Federation will undertake discreet interventions in support of the institutional capacity of ARCS, in the branches and at headquarters. Gaps in HR systems, telecommunications and logistics will all be addressed, while further investments will be made to provide the basic office facilities that many branches and departments still lack.

The Federation's 2004 programme in Afghanistan aims to build on past progress, as the country has an obligation to seize on the current comparative stability and maximise use of available international resources. The programme's overall goal is to continue to ensure the capacity of the ARCS to support the millions of vulnerable people in need of assistance has increased within the year.

Four integrated Federation programmes in health, disaster management, humanitarian values and OD will contribute to achieve this goal. In addition the new element of implementation and management gives added value in terms of coordination, cooperation and strategic partnerships, representation and advocacy, governance support and delegation management.

1. Health and Care

Background

More than two decades of civil war in Afghanistan has left the health sector critically damaged and has had a major impact on the health of vulnerable people, particularly women and children. Several statistics illustrate the gravity of the situation: one woman dies every half hour due to pregnancy related complications and one in four children die before their fifth birthday. In Afghanistan, malnutrition and communicable diseases remain among the most significant causes of morbidity and mortality. The large majority of health services are and have been for the last decades financed by international assistance, without coordinated planning. The health system emerging after decades of conflict is too small, fragmented, used only by a minority of the population, grossly gender and urban biased, concentrated along vertical lines across the country and is severely underfinanced. The gravity of the situation is reflected in some of the worst health indicators found anywhere in the world.

Selected Indicators -- 2002
Maternal Mortality Rate 1700/100,000 live births
Infant Mortality Rate 165/1,000 live births
Under Five Mortality Rate 252/1,000 live births
Life Expectancy at Birth 43 years
Total Fertility Rate 6.8 children for child-bearing woman
Crude Birth Rate 48/1,000 habitants
Crude Death Rate 22/1,000 habitants
Population Annual Growth Rate 4.5%
% of population using improved
drinking water source (2000)
Urban :19
Rural :11
% of population using adequate
sanitation facilities (2000)
Urban :25
Rural :8
% of Immunization 2001 BCG :54%
DPT3:44%
OPV3:45%
Measles:46%
% of population urbanised 23
Source: World Health Report 2002, The State of the World's Children 2003

Outbreaks of communicable diseases have increased health vulnerability especially of women and children in Afghanistan. During the last couple of years outbreaks of measles, pertussis, diphtheria, cholera and meningitis affected thousands of people and left hundreds of casualties.

It is estimated that there are only 500-600 primary health care facilities in Afghanistan scattered heterogeneously throughout the country, leaving the large majority of the population with no access to health services. Hospitals are reported to number between 60 and 100 of varying standards, severely under-used and unevenly distributed with the largest concentration in and around the Kabul area.

Data on the structure of the health workforce is inconsistent but a striking feature is the over representation of doctors numbering slightly less then the nurses and midwives put together. This is thought to be largely a result of the proliferation of training venues in the 1980s and 1990s under a weak central government unable to exercise authority over local decision makers. Distribution is also severely uneven with 68 per cent of doctors and 63 per cent of other health professionals found in the Kabul province. Women represent only 26 per cent of doctors and 30 per cent of nurses. Government community health workers are thought to number around 3000 with varying levels of training from a few weeks up to six months. On the supply side, drug shortages are acute, inadequate imports and poor distribution systems hamper access, quality controls are virtually non-existent and irrational drug use is widespread.

In the face of these formidable challenges the Transitional Islamic Government began a process to determine the major priorities for rebuilding the national health system aiming, over time, to make essential health services available to all Afghans. A basic package of health care services (BPHS) was developed for the purpose of:

  • providing standardised services in primary health care; an

  • providing equitable access, emphasising under-served areas.

The BPHS aims to provide a comprehensive set of health services based on a global system of district health with four standard types of health facilities, ranging from district hospitals with impatient and outpatient services, to health centres with health posts having increasing focus on health promotion and preventive care.

The Federation support to the ARCS began in 1991, running clinics in Kabul. In the ensuing years assistance was gradually extended to support over 50 clinics in 28 provinces and an additional five health emergency mobile units (EMUs) providing primary health care services to vulnerable people. The ARCS has stood strong during the decades of conflict and civil strife, consistently providing essential health care to the huge numbers of vulnerable people in Afghanistan.

The following have been the major achievements in 2003:

  • Around 650,000 people have benefitted from curative and preventive health services in the ARCS clinics.

  • The EMUs responded, in tandem with disaster response staff, to disasters all over the country (such as the Nahrin earthquake), disease outbreaks and floods in many areas.

  • Water sanitation team drilled 320 new boreholes and deepened two existing boreholes in the south and western regions allowing large numbers of vulnerable people to have much needed access to safe drinking water. Some 232 latrines have been constructed in the same regions and around 4,000 families have been reached with hygiene messages, which have a known impact of reducing waterborne diseases in the community.

  • Some 2,500 new volunteers from about 1,000 villages were recruited and trained in hygiene and health promotion joining the strong team of over 15,000 CBFA volunteers country-wide.

  • The above success has been built on the following:

  • A national network of 50 clinics providing preventive and curative services including health education (regarding hygiene, breast feeding, nutrition, immunisation, water and sanitation), vaccination of mothers and children, family planning and other maternal and child health services.

  • Five EMUs responding to emergencies and providing health care services to vulnerable people living long distances from health facilities.

  • A strong water sanitation team in the southwest providing safe drinking water to thousands of people suffering from lack of access to clean water in sufficient quantities.

  • A CBFA project where the ARCS has built a network of trained volunteers throughout the country. During the last five years more than 15,000 volunteers have been trained to provide first aid and health education to people in thousands of villages. Since the inception of the programme six years ago, they responded effectively in disasters, the first on the scene in many cases. The importance of this vast network becomes apparent when considering that community health workers in the country are estimated by the World Health Organisation to number only 3,000.

In the face of changing realities the Federation supported ARCS in analysing how the altering contexts would affect the society and its health programmes. Focus was specifically on ways to adapt activities to the changing contexts and maximising the impact of ARCS in serving vulnerable populations in accordance with the Movement's principles.

For many years the primary health care programme has stood strong, ensuring essential health services each year to nearly a million Afghans in perilous times of political instability and conflict. The clinics have been crucial in alleviating vulnerability but have also been central to the identity and development of the ARCS -- particularly at branch level.

The newly formed government is now taking on responsibility for health service delivery. Government policy is to draw in new service providers in health, and provide BPHS covering different provinces and districts. Part of the implementation of the BPHS will be through a system of performance-based partnership agreements (PPA), based on health sector reconstruction. The challenge for ARCS will be to redefine its services to meet changing contexts through partially scaling down clinics where appropriate, while at the same time developing new services and scaling up the CBFA and EMU components.

In 2004, three clinics will be closed, while five others will be converted to social support centre (SSCs); ten other clinics will be upgraded to the new national standards while five will be relocated to under-served areas. This will mark the start of a radical realignment -- one that will continue in the coming two to three years during which time it is crucial that donor support be sustained to allow for a successful transition. The ARCS will seek to withdraw from clinics in areas where other agencies are moving in to implement the partnership agreements as part of the BPHS. In under-served areas the society will maintain its clinics or extend them through relocation, while also using the EMU to provide a mobile clinic service to remote areas in addition to responding to emergencies.

The extensive network of CBFA volunteers is important in todays health sector context in Afghanistan. Health promotion -- prevention of communicable diseases, hygiene education, immunisation activities, HIV prevention and first aid -- will be among the many areas targeted by a growing number of CBFA volunteers, supported by consistent supervision and training. The range of their activities will also be expanded in order to provide a greater service to their communities, as well as to help motivate them, with closer links to branches, EMUs and the disaster management (DM) programme.

The EMU have consistently proved their value, as was evident from the response to the Nahrin earthquake during the first half of 2002. They have also been used during disease outbreaks and other emergencies throughout the country and can play a key role through integration into a larger national system of epidemic surveillance and response, currently being developed. During normal situations EMU provide health care services in remote areas, with little access to health centres.

The health programme has great potential to increase its impact through further linking of hygiene education with drilling wells and constructing latrines.

New health projects will be tested and developed with an emphasis on unmet needs, starting with health education, disability and HIV/AIDS. The new social support centres will provide one platform for the emerging services. Service concepts will be developed and tested locally depending on the priorities of particular communities working towards maximising sustainability of the health programme components - analysing cost recovery schemes, cost reduction, income from properties and small enterprises. Cross-learning from different initiatives around the country and the South Asia region will be important to the development of the programme and the Federation will promote and facilitate exchanges and information sharing.

Overall Goal

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

Programme Objective

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

The programme comprises four projects, whose objectives are reduced vulnerability via:

1. Basic Health Centres

To provide health care services to the vulnerable people of Afghanistan through ARCS health facilities.

2. Emergency Mobile Units

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.

3. Environmental Health

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.

4. Community Based First Aid

To deliver preventive health services such as first aid, health education, HIV awareness, participation in immunization campaigns, particularly in rural communities, through community based volunteers linked to branches and health centres; further to the continued provision of timely response to disasters and disease outbreaks.

Programme title
2004 in CHF
Strengthening the National Society
Health and Care
6,436,581
Disaster Management
1,749,292
Humanitarian Values
867,682
Organisational Development.
2,037,108
Total
11,090,6631

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