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Cordaid in Uruzgan: promoting health care in a war zone

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Despite the odds of war, Uruzgan’s health care system is getting better and stronger. Has Cordaid’s 2001-2018 commitment in the Afghan province anything to do with this encouraging fact? And how did we stick to our health care mission in the complexity and volatility of conflict? One Dutch and one Afghan expert come with answers to these and other questions.

Uruzgan: one of Afghanistan's most challenging provinces

But first, some background. Today, despite ISAF's massive efforts between 2001 and 2014 to train the Afghan army and help rebuild government institutions, the Taliban control between 80% to 90% of Uruzgan province. With its 400.000 inhabitants living in sparsely populated (semi)mountainous terrain, and most main roads beyond government control, it is one of the most challenging of all Afghanistan's 34 provinces.

'Ten Years Later: An Assessment of Uruzgan Province a Decade after the Dutch Military Departure', clearly shows how Uruzgan's security situation, its education system, and its economy have seriously deteriorated in recent years. Yet, this assessment conducted by Afghan research organisation The Liaison Office and commissioned by Cordaid, also gives one firm reason to keep investing in progress: despite all the odds and the ongoing war, health care in Uruzgan has significantly improved.

The assessment points out that between 2010 and 2020, the number of health centres tripled. Staff, including the number of female nurses, increased. Medically attended deliveries surged from 2.6% in 2006 to 70% in 2020. And between 2003 and 2015, under-5 child mortality dropped by 34%. To mention just a few indicators.

The backbone of primary and secondary health care

From 2001 to 2018, Cordaid was one of a few INGOs in Uruzgan, strongly committed to strengthening its health care system. "We opted for the long haul, and it paid off", says Cordaid's Albert van Hal, who was closely involved in the Uruzgan health program at the time. Both van Hal and Hameed Attaiy, Cordaid's current Afghanistan Programme Director based in Kabul, attest to the lasting impact of Cordaid's health efforts in the province. Our long-term strategy and close collaboration with Afghan partners such as the Afghan Health and Development Services (AHDS), definitely contributed to today's comparatively strong health care system in Uruzgan, they claim.

Between 2001 and 2018, in partnership with AHDS, Cordaid established and ran 56 health facilities and 472 health posts. All of them prioritized health services for young mothers and children. AHDS and Cordaid improved access to and quality of both the basic package of health services (BPHS) and the essential package of hospital services (EPHS). These packages are the backbone of the primary and secondary health care systems, and of vital importance to Uruzgan's population of 400.000.

Training midwives, nurses, and technicians

The harshness, isolation, and insecurity of rural life in Uruzgan make it very hard to recruit and keep qualified health staff. Finding qualified female staff, so important because cultural orthodoxy forbids women to be treated by men, is even harder.

With Cordaid's support, AHDS trained 85 community midwives and 47 female nurses in Uruzgan alone. Our financial and technical support of the Kandahar Institute of Health Sciences turned out to be of national importance. As part of the Cordaid programme, the Institute delivered graduated midwives, nurses, lab, and pharmacy technicians. They were posted to all corners of the country. 93 of them went to work in Uruzgan.

The price of progress

One of them is 27-year old Gulali Mohammadi. She talked her way into studying at the Kandahar Institute. Later, at age 27, defying death threats from her brothers, she went on to become Afghanistan's youngest member of parliament, shaping health and gender policies in the country's political epicenter, Kabul. Noël van Bemmel from de Volkskrant recently wrote her story.

Mrs. Mhammadi's story is spectacular, but also exceptional. For many Uruzgani families, even those who were willing to send their daughters to higher education, Kandahar was simply too far away. "This is why we started community midwifery education nearer to them, in Tirin Kot", van Hal explains.

Progress made in Uruzgan's health system is deeply encouraging and hopeful. But it comes with a sacrifice. Over the past years, in Uruzgan province alone, AHDS has lost 20 of its staff. Doctors, nurses, midwives, vaccinators, guards, cleaners, killed accidentally while doing their jobs. They were very well aware of the security threats yet continued to reach out to others. AHDS remembers them as 'health care martyrs'.

Looking back and sharing lessons

Two years after Cordaid's health care program in Uruzgan came to an end, we asked two of our colleagues to look back. Health expert Albert van Hal, based in the Netherlands, and Kabul-based Programme Director Hameed Attaiy, share the inside story of promoting health care in one of the world's most war-torn and militarized zones.

Health expert Albert van Hal was programme manager Afghanistan from 2008 until 2014. In 2014 he was Cordaid's Country Director Afghanistan, based in Kabul. Van Hal currently coordinates health programmes in Iraq and Yemen and is also an advocacy advisor for Afghanistan.

Hameed Attaiy is Cordaid Afghanistan's Programmes Director, based in Kabul. From 2008 to 2018 he was involved in Cordaid's health programme in Uruzgan in different roles as Head of Finance, Head of operations and Deputy Country Director.

What does it take to structurally improve a health care system in a volatile and insecure setting such as Uruzgan?

Van Hal: You need to focus. And you need to be willing to stay for a longer period. In our case this was from 2001 to 2018.

Afghanistan is an arena of hundreds of conflicts within conflicts. You can only make a difference if you narrow down your interventions. That's what we did in 2008. We limited our intervention areas to 6 provinces and focused on Balkh, Kandahar, and Uruzgan. In Uruzgan, health care was our first and main priority.

From then onwards, things started rolling. With EU funds, Cordaid and AHDS successfully strengthened and staffed clinics and hospitals. With KIHS we enrolled and trained Afghan female nurses and midwives. This was crucial. Men in Uruzgan all want their wives and daughters to be cured when in medical need, but they do not allow them to be treated by men or strangers.

Our work led to more patients finding their way to health facilities and it improved service delivery. This didn't go unnoticed. The EU gave us more projects. Other donors started approaching us, including the Dutch Ministry of Foreign Affairs, and Unicef. During field trips, I managed to leave the provincial capital Tarin Kot a couple of times to visit the health facilities we supported. Every time I was elated by the progress I saw: more female staff, more female students braving restricting traditions to attend the midwifery education in Tarin Kot, more access to nurses and doctors.

How do you gain trust as a foreign NGO in a war-affected province?

Van Hal: In a conflict zone, suspicion and distrust dictate social relations. Building community relations and gaining trust from tribal leaders takes a lot of time. As a Dutch guy representing a foreign NGO, I wasn't the first person to do this. Our Afghan colleagues from AHDS were. They spent days and days, talking and drinking tea with community leaders in each and every village. Slowly we gained their trust and their cooperation.

'Sometimes armed groups want you to increase services in the areas they control. Thanks to community involvement and negotiations by tribal leaders, we always managed not to yield to these forms of pressure.'

Hameed Attaiy

Tribal leaders were essential negotiators every time we met with challenges and obstacles. Also in dealing with the Taliban. If you want to open or run clinics in Taliban controlled areas -- which is what you want to do in order to alleviate suffering among an extremely underserved population -- you need to work with tribal leaders. It takes trust, time, and dialogue.

I remember how doctor Noor, the director of AHDS in Uruzgan, hung on the phone litterally the whole day. He kept on talking to tribal leaders, checking and double-checking, negotiating safe passages for staff and patients, medicines, and equipment. He could only do that because people trusted him, AHDS, and Cordaid. And they trusted Cordaid because they saw the results of our work on the ground. Trust is the result of words and deeds.

What is your experience, Hameed?

Attaiy: Indeed, trust is key. When tensions are rising, and people's lives are on the line, community acceptance is what can save you. For that you need trust. Cordaid's bottom-up approach, putting community needs at the center of everything we did, was instrumental in this respect. We put communities in the driver's seat of our programme activities. Their needs, their vision, their sensitivities were leading. And, not unimportantly, Afghan staff ran the health posts. Not foreigners.

'Trust pays off in many ways, also in terms of security, and program continuity. But donors do not always take these things into account.'

Albert van Hal

The fact that we implemented a health care programme was of great importance as well. It is a lot less controversial as, for example, peacebuilding or gender equality initiatives. Everyone, whether it's a mother, a child, a father, an armed fighter or soldier, or a government official, needs a doctor when they are ill or wounded. Whoever controls an area, all parties want medical facilities to be functional.

Later on, this health care reputation allowed us to expand our work in other fields, like economic empowerment and dialogue between communities.

Being innovative also helped to establish our reputation. Cordaid was the first to introduce performance-based financing in strengthening the Uruzgan health system. This improved the quality and efficiency of care, especially in the provincial hospital. Later on, the Afghan government included PBF (RBF) in its national health policy.

Right in the middle of Cordaid's Uruzgan health program, from 2006 to 2010, Dutch military forces were deployed in the Task Force Uruzgan mission, which was part of ISAF. How did this impact Cordaid's work? And how did Cordaid, as a Dutch INGO, deal with this Dutch military presence?

Attaiy: By 2006, Cordaid had already established its trustworthiness. Notwithstanding people's distrust towards foreigners, Cordaid had a solid reputation in the field of health care. Dutch military presence did not undermine this reputation. After 2007, when Taliban control increased, things became more problematic. We had to be very careful in maintaining our independent position as a non-governmental organisation.

Van Hal: For me, it was essential that our staff dissociated themselves at all times from the soldiers in the field. We made it very clear that we could not be seen with them. Respectfully, of course. The reason is very simple: without sticking to this principle, the Taliban could have targeted our doctors. There were casualties among our medical staff, as I said before. But this was collateral damage, not the result of deliberate attacks.

And, primordially, as a humanitarian organisation you have to stay neutral in any circumstance. By associating ourselves with the Dutch military we would have breached that basic rule.

The Dutch mission in Uruzgan also had a financial consequence: government funding for Dutch NGOs in Uruzgan increased. Which was to our advantage. And I also need to mention that we maintained excellent relations with Dutch diplomats in Uruzgan, without jeopardising our NGO independence. They helped us to solve problems.

Staying neutral in a volatile setting, with shifting areas of control, a host of armed and unarmed actors, being a Dutch NGO in times of a Dutch military mission, seems like a hell of a job. How did you do that? Van Hal: It is complex like you say. Take the clinic and hospital buildings. These were the property of the government. Yet some of them were in Taliban-held areas. AHDS contracted the medical staff, Cordaid financed the salaries, as well as the stocks of medicines. Many parties, many ties, many interests. And more nuanced than a lot of outsiders think. Taliban leaders were not interested in controlling or claiming health facilities. They wanted them to be functional.

‘Limit your intervention zone. Stay away from soldiers. Stay for a long time. And keep talking. To everybody. Always.’

Albert van Hal

In the end, it boils down to something clear and simple: offering good quality health care services to all parties. This inclusivity is what protects you as a service provider and as an INGO.

Attaiy: For a doctor or a nurse, there are no civilians, fighters, or soldiers. There are only patients.

Of course, there is pressure from many sides. Sometimes armed groups want you to increase services in the areas they control. Thanks to community involvement and negotiations by tribal leaders, we always managed not to yield to these forms of pressure. And to do the things we wanted to do, in the way we wanted. It just takes time and flexibility.

For example, at one point warnings and threats of anti-government elements led to the closure of 35 of our health facilities. In the end, the community health Shuras or committees we had worked with closely, successfully lobbied for their reopening. It took them three months. Trust takes time.

Our health care programme in Uruzgan stopped two years ago. Is today's comparatively strong health care system in the province a legacy of Cordaid's efforts?

Attaiy: At least partly, yes. Most of the clinics and hospitals we ran with AHDS are still there. We were transparent, trustworthy. And most of the staff we trained and enrolled are still working. In Uruzgan, that is an accomplishment. Today, anyone in Uruzgan who talks about health care talks about Cordaid and AHDS.

'Community shuras successfully lobbied for the reopening of health facilities. It took them three months. Trust takes time.'

Hameed Attaiy

But we cannot claim full honours. In times of war, clinics are better protected than schools, companies, or government buildings. We have to thank health care itself for that.

Van Hal: We did well. I have been doing this line of work for a few decades in different parts of the globe. Cordaid's and AHDS's health care work in Uruzgan is one of the jobs I am most proud of. And yes, even though the program has stopped -- to my deep regret -- I think this work has had a lasting impact. At least until now.

Why did we stop?

Van Hal: Painful question. We stopped because we lost important donor bids. In the end, our track record, our reputation, and the trust we had gained did not outweigh the fact that the costs of Afghan NGOs were lower than ours. Trust pays off in many ways, also in terms of security, and program continuity. But donors do not always take these things into account.

Attaiy: 2018 was an exceptional year, in that Afghan NGOs replaced most international NGOs. Which is also positive.

What is the most important lesson you have learned from your health care experience in Uruzgan?

Van Hal: If you want to deliver in a war zone, you have to stick to tough choices. Limit your intervention zone, geographically and thematically. Stay away from soldiers. Forget the quick fix, stay for a long time. Don't leave when others leave. And keep talking. To everybody. Always.

Attaiy: Put communities in the lead. Take time to build trust and to keep it.

After Uruzgan, did you try to put these lessons into practice in other volatile parts of the world?

Van Hal: Another painful question, I am afraid. We always try and sometimes succeed. But so much depends on the big donor agencies. They want results and they want them fast. Today, they hardly allow you to implement programmes that exceed 5 years. That's not enough to create the kind of impact that survives the volatility of conflict. Like we did in Uruzgan.

Read & watch more

Read more about delivering health care in Afghanistan and Cordaid's approach to it in this Devex article. Devex also wrote an article zooming in on the importance of trust and negotiation for health care service delivery in volatile settings.

Or watch this video, showing how Cordaid supports the health system in Afghanistan.

This country page gives you an overview of all Cordaid's activities in Afghanistan.