La Fontaine des Marins

26170 Plaisians – France

This mission is both the end-product and result of a complex process and interactions between many stakeholders. It would be impossible to mention them all individually but we would like to take this opportunity to thank the organisations, institutions and people who allowed this exercise to take place in optimal conditions, allowing us to collect a sizeable amount of information.

First of all, we would like to thank the organisations that supported the mission, facilitated logistics and accommodated the team in the field. At the forefront, the support from Solidarités and ACTED, as well as from AMI and ACF, was very substantial. Our sincere thanks go to those NGOs as well as to their Paris and field teams.

Other actors donated their time to accommodate us and often took us on tours of their projects. We would like to express our recognition to several NGO teams (See "List of Organisations" in Annex 1), the ICRC and the United Nations machine (UNAMA, UNHCR, WFP, FAO, UNMAPA , UNICEF, WHO).

Our colleagues from ACBAR, AREU and AIMS, three key structures for international aid to Afghanistan, provided us with permanent support.

Our Afghan friends and partners, as well as the populations in the zones visited, always gave us a warm welcome. The outstanding Afghan hospitality never went unheeded and we thank them wholeheartedly for it.

Lastly, such a mission could not have taken place without the financial, operational and intellectual support of the donors behind the Quality Project work in Afghanistan: ECHO, the Swiss Cooperation and the Fondation de France (FDF).

The Quality Project team

Map of Afghanistan

The Quality Project, currently in its research/development stage, is aimed at developing, testing and making a self-evaluation and self-learning tool available to humanitarian actors. The ultimate objective of this "quality tool" is to participate in the improvement of the quality of humanitarian action, and in particular the quality of the services rendered to populations suffering from crises and catastrophes.

A quality approach, using the quality tool based on the project cycle phases, will make it possible to question and evaluate the critical points of any humanitarian program, in particular the initial diagnosis, project design and follow-up/evaluation phases.

This quality approach will be aimed at limiting the risk of error (identifying critical points, looking for errors and malfunctioning, correcting them) and at the risk of repeating errors (collective situational learning): it is based on the "question/evaluate-correct/learn" tripod.

The approach for elaborating the quality tool developed by Groupe URD, in partnership with a network of NGOs, university scholars and researchers, has several unique characteristics:

It is a multidisciplinary approach: the research team is pluriprofessional, associating specialists in public health, nutrition, housing/urbanism, agronomy/food security, international humanitarian law, and quality assurance; these fields cover the majority of those called upon in crisis situations.

It is a multi-temporal approach: as crisis situations, almost by definition, are essentially ever-changing, the research team carries out several missions at each of the sites visited, in order to assess the humanitarian actors’ capacity to adapt to the evolving situation. The importance of this multi-temporality is reinforced by the fact that the impact of humanitarian action in complex, and often protracted, crises cannot be measured in a single visit. The secondary effects, whether positive or negative, generally emerge only over time.

It is a multi-actor approach: throughout each mission, programmes set up by a wide range of actors are visited: national and international actors, NGOs and UN organisations, etc.

It is a participatory approach: in addition to numerous interviews in the field with the workers, national officials and beneficiaries, the missions always end with in-field feedback sessions followed by exchanges and debates with the field workers. Upon their return, a feedback session is organised along with an initial report used as a communication tool. These exchanges make it possible to validate or invalidate assumptions, and enhance reflection.

The idea of launching an evaluation-learning process in Afghanistan dates back to December 2000. Within the framework of the international Conference organised by Groupe URD and Médecins du Monde (MDM) on the topic of forgotten, protracted crises, Afghanistan was indeed already one of the central topics. At the end of the conference, many participants wanted the studies concerning Afghanistan to be continued and expanded, on the same basis as Groupe URD’s evaluation-capitalisation-learning studies conducted in Central America (particularly post-Mitch). The current events that followed September 11^th reactivated the process.

This July-August 2002 mission in Afghanistan is therefore the first Afghan mission by the Quality Project research team: it will be followed by two other missions, in the winter, then the summer of 2003.

This report is broken down into several parts:

The first chapter presents the overall mission methodology, particularly the criteria having governed the elaboration of the itinerary and the sampling of zones and projects to be visited.

The second chapter, in the form of an introduction to the Afghanistan context and to the background of the humanitarian intervention in that context, makes it possible to define the international intervention process in the timeframe in which the current mission takes place.

The short conclusion deals with the process still to come in Afghanistan, and with the consequences of the first mission.

Several annexes provide the reader with mission details (itinerary, list of organisations, etc.).

ACF Action contre la Faim (Action against Hunger)

ACTED Agence d’aide à la Coopération Technique et au Développement

AHDS Afghan Health & Development Services

AIMS Afghanistan Information and Mapping System

AMI Aide Médicale Internationale

AREU Afghanistan Research and Evaluation Unit

ARI Acute Respiratory Infections

BSC Beneficiary Selection Committee

CDC Center for Disease Control

CF Community Forum

ECHO European Commission for Humanitarian Aid Office

FAO UN Food and Agriculture Organisation

Groupe URD Groupe Urgence Réhabilitation Développement

HCR UN High Commissioner for Refugees

ICARDA International Center for Agricultural Research in Dry Areas

ICRC International Committee of the Red Cross

ICRISAT International Crops Research Institute for the Semi-Arid Tropics

IDP Internally Displaced Person

IRC International Relief Committee

MCH Maternal and Child Health

MDM Médecins du Monde

MOPH Ministry of Public Health

MRCA Medical Refresher Courses for Afghans

MSF Médecins sans Frontières

NGO Non-governmental Organisation

PPA Performance-based Partnership Agreement

QP Quality Project

SFC Supplementary Feeding Centre

STF Save the Children Fund

STP Solid Therapeutic Product

TDH Terre des Hommes

TFC Therapeutic Feeding Centre

UN United Nations

UNO United Nations Organisation

UNAMA United Nations Mission for Afghanistan

UNCHS UN Commission for Human Settlements

UNPICD United Nations Programme for the International Control of Drugs

UNDP United Nations Development Programme

UNHCR United Nations High Commissioner for Refugees

UNMAPA United Nations Mines Action Programme for Afghanistan

UNICEF United Nations Fund for Children

WHO World Health Organisation

WFP World Food Program

WWF World Wildlife Fund

The purpose of the field mission was three-fold: (i) to get a thorough understanding of the range of humanitarian interventions and strategies; (ii) to identify what made health projects successful or problematic; (iii) to raise issues pertaining to the quality of humanitarian interventions and stimulate a debate with agencies and key stakeholders.

The multidisciplinary team included three members from Group URD and two independent consultants. It was gender-balanced, including two women and three men. There was good knowledge of Afghanistan within the team, with three members having been actively involved in the country and/or in refugee camps in Pakistan.

The mission’s approach was to conduct a joint team exercise, throughout a multi-phase process. During the preparatory phase, a considerable amount of time was spent on developing a common methodological framework. In addition, an overview of assistance in Afghanistan was obtained from relevant documentation and visits to the head offices of the Quality Project’s partners in Paris. Two Group URD members facilitated the preparation of the fieldwork, by spending a week in Kabul organising the logistics and disseminating information concerning the mission.

The ethnic composition

of the population

In order to build a balanced picture of the humanitarian assistance in Afghanistan, and to encompass a wide range of situations, the design of the itinerary took into account four types of criteria: the ethnic diversity in the country; the diversity of humanitarian contexts and situations (urban versus rural, natural disasters –earthquake, drought–, conflict, IDP camps, return of refugees); the representation of international and national NGOs; and the density of projects.

The combination of these four criteria led to the following itinerary: Kabul and the Shamali Plain, the Panshir Valley, the central (Bamyan), northern (Ruyi du Ab, Mazar-e-Sharif Nahrin, Pul-e-Khumri) and southern (Kandahar) parts of Afghanistan. Access to most areas was by road, a trip that proved enlightening as it allowed the team to capture the reality of rural areas and the constraints posed by the terrain.

The detailed programme of activities is attached as Annex 1. Information was gathered using semi-structured interviews with key informants and direct observation of activities at project sites. The main stakeholders interviewed included beneficiaries, local and national authorities, aid workers from local and international NGOs, and representatives from the UN and ICRC. In-depth interviews, combined with formal and informal meetings with aid workers, contributed to clarify the mission’s objectives, to overcome defensive behaviours and to reconstruct project processes. The views of beneficiaries and community members were recorded through individual interviews and focus groups, with the assistance of an Afghan translator.

At the end of the mission, a feedback session, which involved exchange and debate with aid actors and key stakeholders, was held in Kabul.

On the whole, exchanges with interviewees were very positive. Aid workers welcomed the opportunity to share their experiences and raise issues of concern. The open and constructive responses obtained in general were highly appreciated.

The following constraints tended to hamper the field work:

• Difficulties to construct the project history due to the high turnover of aid workers;
• Limited access to project documentation;
• Due to the mission time-frame and security problems, projects located in the eastern and western parts of the country were not visited;
• Time constraints and the lack of a female translator, especially for the Southern Region, limited the possibilities to gather beneficiaries’ and community members’ perspectives.

In over twenty years of war in Afghanistan, the stakes, dynamics, and parties in the conflict have continually evolved. Initially one of the scenes for the Cold War during the Soviet Invasion, the Afghan war has continued after the fall of the communist regime. One can no longer speak of an ideological confrontation; the war has turned to a local conflict, fuelled by the geopolitical strategies of neighbouring powers (Pakistan, Iran, India, Saudi Arabia), and grounded in tribal and ethnic oppositions. The situation is further complicated by the political positions of great world powers: the United States and their fight against Al Qaida and opium production; the European Union and gender issues; the United Nations and the "Strategic Framework" for the political and humanitarian rehabilitation of the country, etc. The situation continues to be tragic, due to the severity of the ongoing drought, the forced repatriation of refugees from Iran and Pakistan, and the ongoing hostilities in certain areas (around Mazar, Kunar, etc.). The events following the 11^th September 2001 have changed the course of history. Within a few months, the country has engaged on what may be a road towards peace, though the challenges involved are great, as the political and humanitarian situation remains uncertain and precarious.

In 1973, a socialist coup d’état put an end to the monarchy. The modernist reforms of the new regime, by tackling land tenure issues too abruptly and challenging traditional social relations, gave rise to discontent and increasing instability in rural areas, throughout 1978 and 79. The Kabul regime appealed to the Soviet Union for assistance. Attracted by Afghanistan’s strategic position in terms of access to southern seas and oil, the Soviets deployed the Red Army in full force. The Afghan war became a key stake in the Cold War, with Western countries supporting the Mujahiddin resistance. The Perestroika and the development of the "détente" brought about the withdrawal of Soviet troops in 1988, and gave rise to a period of relative stability between 1988 and 92.

Unfortunately, peace did not last as fighting broke out between Mujahiddin factions, previously allies in the resistance. The conflict took on a political and ethnic dimension, with Pashtuns and Uzbeks accusing the Tajiks of having confiscated the political control, while the latter engaged in violent conflict with the Hazaras. This phase of the civil war was essentially characterised by a series of sieges and offensives between the various factions around Kabul, which was heavily bombed; entire neighbourhoods in the capital were destroyed. The Mujahiddin commanders imposed their control throughout the country, while power relations were based on patron-client lines. There no longer were any regulatory bodies or authorities. The war took place in a restricted space, in small bouts; its aim was neither to topple the State nor its adversaries, but to strengthen one local faction or leader against others. The future political system was not the stake of the conflict.

The economy was devastated, leaving the population in evermore precarious living conditions. As the security conditions continued to deteriorate and predation of civilians increased, a sense of exasperation developed among the population. This paved the way for the Taliban movement, born in the madrassas (Koranic schools) in neighbouring Pakistan.

The crisis took on a new ideological dimension, and the balance of power shifted with the arrival of the Taliban, a movement based essentially among Pashtun groups in the south and south-east of the country. The Taliban, supported by Pakistan, and initially, at least, by the United States which sought to clear an access to Central Asia, gained control of most of the country and imposed a regime of political and religious repression, notably in Kabul. Women, deprived of education, health care and employment, were the first victims of this regime. Though the Taliban were initially welcomed in many areas by a population tired of the banditry of local commanders, the new masters of 20%, then 50% and finally nearly 80% of the Afghan territory, soon revealed their true face. Stonings, hangings, public executions, beatings, incarcerations, etc. became the daily lot of the Afghan population.

The intervention of the Coalition forces, under the leadership of the American government, and through support to the Northern Alliance (previously led by Commander Masoud until his assassination on the 9^th September 2001), led to the collapse of the Taliban regime, a few days before the start of Ramadan, in November 2001. A complex process of political reconstruction is being put in place since, under the auspices of the United Nations. It aims to gradually build and strengthen the capacity and legitimacy of the central government in Kabul, a government that is still trying to find its marks in rural areas, in a context that remains highly insecure.

A devastated country :

Afghanistan is one of the poorest countries in the world, and has one of the lowest human development indicators. The economy, traditionally based on agriculture, has been greatly affected by the various phases of the conflict. A large part of cultivable land is inaccessible due to the presence of landmines, despite the huge efforts undertaken in demining activities. Health and education services, as well as the banking system, are quasi-inexistent, or reduced to simple and degraded infrastructures. The drastic lack of financial and human resources in the new administration leaves the population in complete destitution. The new regime is attempting to improve the human rights situation, which remains precarious, while aggressive strategies in the field of women’s rights, especially in rural areas, are still far from bringing women’s situation close to international standards.

The absence of a State able to control the territory and meet the economic needs of the population and of the commanders in particular, has generated an upsurge of opium production. The development of illicit activities has become a central stake in the conflict. The Taliban controlled 97% of opium production areas and received a tax that contributed to their finances. In July 2000, Mollah Omar completely banned poppy cultivation for 2001. His representatives went from village to village in poppy production areas, telling farmers that the drought was a punishment of Allah for having practiced the unholy cultivation of poppy. The message was generally heard, and in October-November 2000, farmers did not sow poppy, except in the North-East. This measure was theoretically a way for the Taliban to clear their records at a time when they were once again claiming the representation of Afghanistan at the United Nations. The events of September 11^th have changed the course of events. However, in the current context of drought and economic insecurity, opium represents the most profitable crop and a unique source of cash for farmers, such that poppy cultivation is spreading throughout the country. Furthermore, faced with a destroyed economy, a vast smuggling network has been put in place with neighbouring countries, destabilising the whole region.

The years of war have made the Afghan refugee population the largest in the world, the majority having fled to Iran and Pakistan. After having exceeded 4 million, the Afghan refugee population is now estimated to be 2.6 million. The economic recession in the two host countries is inciting their governments to push for the repatriation of refugees, despite the precarious security and economic conditions in Afghanistan. The civil war and the drought have contributed to slow down the return process. The drought that has been striking the region since 2000, especially in the Central Highlands, the Northern Region and Southern Belt, has indeed hit families hard, causing very poor harvests and loss of livestock, and leading thousands of families to sell their assets, become deeply indebted, and even leave their homes. An estimated 300,000 people are currently internally displaced (IDPs), some of them grouped in camps in various areas of the country (Herat, Mazar, Pul-e-Khumri, Kandahar). Others attempted to flee to Pakistan, until the fall of the Taliban and even during the American intervention, though Pakistan continued to be reticent to welcome them. Fortunately the massive exodus that was expected did not take place. On the contrary, as soon as the hostilities ended, Afghans living in camps started returning massively, no doubt prompted by the host countries. In a few months, a large part of the 3 million refugees have returned both towards urban centres and their rural area of origin. The country’s capacity to absorb these returns remains limited, however, given the devastation caused by the war and the ongoing drought. It is feared that the current refugees and IDPs and recent returnees have not seen the last of their travels.

The duration of the afghan conflict, its numerous phases and various manifestations, have brought about several phases in the humanitarian response. These are presented by chronological order below:

The pioneers  (date: 1979-88): Initiated from the outset of the Soviet invasion, this phase marks the beginnings of humanitarian aid as we know it today. It is the period of the "French doctors" and of the "without borders" movement in its purest form : crossing of mountain passes at night, illegal convoys, and essentially medical interventions for the "freedom fighters". It is also the beginning of large operations in the management of refugee camps, which served as a base for the guerrillas. This phase is marked by the romanticism of numerous men and women engaged in the field, who, with some naivety, were often controlled by the commanders inside the country or by the Shura in Peshawar. The period ended in 1988-89, with the signing of a peace agreement and the withdrawal of the Red Army. During these difficult years, the UN’s role was typical of the organisation’s throughout the Cold War: UNDP was in Kabul but paralysed by the Soviet-Afghan administration and the lack of means due to the embargo imposed by Western governments, while the humanitarian branches of the UN, notably the HCR, were working in the camps (nests of the resistance movements), with considerable financial and food resources.

Operation Salam : Operation Salam, initiated in 1998, paved the way for the first large involvement of the UN and its agencies in rural areas. Its objective was to prepare the return of refugees. However, weakened by a lack of means, poor knowledge of conditions prevailing inside the country and by the lack of operational partners in the field, Operation Salam has had a rather limited impact. During this phase, the network of Afghan NGOs and the culture of "sub-contracting" are born. The lack of field operators inside the country had indeed led the Operation Salam team to encourage the creation of such NGOs, via Afghans living in camps.

The first civil war following the withdrawal of the Soviet troops (1992-96): This period is when the capital city underwent the worst damage. Very large relief programmes were implemented by the International Committee of the Red Cross (ICRC) and by the World Food Programme (WFP) via NGOs. In other regions, the political situation was relatively stable, though the security conditions deteriorated with the growing banditry and illegal activities of local commanders. In these regions, NGOs, the ICRC, and UN agencies developed activities that were rather development-oriented, as opposed to relief activities. This said, the UN maintained a relatively low presence inside the country. Entire zones remained very difficult to access, in particular the Central Highlands, due both to logistic conditions, and the continuation of the conflict between the government in Kabul (under Tajik control) and the Hazara factions.

A coordination system was put in place, the tripod "Islamabad-Kabul-Peshawar", which has had important consequences for the future: Most UN organisations and donor representatives settled in Pakistan’s capital city, while most NGOs kept their base in Peshawar, from where they carried out assistance programmes in the camps and "cross-border" operations. A small dynamic is born in Kabul, around the ICRC, a few NGOs and the UN Habitat office, while most actions were implemented on the Peshawar-Jalalabad axis. During these years, NGOs combined development approaches and relief operations, according to the zones, needs, and evolution of local situations. Some donors, notably the European Union, found modalities and complementarities between budget lines to enable this flexibility.

The Taliban phase (1996-2001): The Taliban policies gave rise to strong tensions with humanitarian organisations. Several crises occurred, leading in particular to the temporary eviction of all NGOs based in Kabul and other permanent evictions, as well as to serious security concerns for United Nations personnel. The sanctions applied by the United Nations, the weakness of the UNHCR with regards to the forced repatriations, and the budgetary restrictions of the European Commission (e.g. ECHO) did not facilitate the provision of assistance to a population which continued to suffer from the conflict and was seeing the beginning of one of the harshest droughts in the century.

The American intervention (Sept-Nov 2001) : September 11^th and the quasi-immediate identification of Ousama Ben Laden –a figure well-known to observers of Afghanistan– as a key instigator led to the rapid evacuation of the expatriate teams, while the majority of their Afghan colleagues stayed behind, to continue to run the programmes as best they could. An impressive mobilisation took place around the country, in the expectation of a massive exodus of refugees which did not occur. This period also saw the practice designated as "one bomb, one bread" be heavily criticised. The confusion between humanitarian and military operations, which is used as a means of propaganda, is still maintained. Inside the country, NGOs working already for some time in the zones controlled by the Northern Alliance, continued to strengthen their presence from Tajikistan. They were the first to enter Kabul, "freed by the BBC".

The first phases after the conflict : The period between November 2001 and April 2002 will probably be remembered as one of confusion, during which the concerns to gain access to donor funds and to have visibility ("fly agency flags") were among the strongest driving forces in the deployment of aid. At the very beginning, the main concern is access: while many volunteers and convoys were blocked by Uzbekistan, airline tickets for flights between Islamabad and Kabul were negotiated at US$7000 for a one-way trip, such were the insurance premiums. Very soon, the situation stabilised and there was a rush of hundreds of agencies in the country, some of which had never been there before. The Afghan government, faced with this wave of organisations, over-equipped in land-cruisers and modern communication systems, had an understandable reaction of rejection. The situation is calming down, though NGOs still have to prove their efficiency in responding to the huge needs of the population.

Political stabilisation and present stakes : With the Loya Jirga (Grand Assembly) and the process of legitimisation of the new government, new questions are being raised regarding the practices of aid agencies: what kind of post-crisis strategies should they adopt and how should control be devolved to Afghan institutions? With what local human resources? With what kind of relationship between the central government in Kabul and the local power structures in the provinces? In this context the new Afghan government is attempting, through its own means and with support from the international community, to put in place frameworks and procedures for the reconstruction and development of the country.

Over the past 20 years, health has been one of the key areas of international assistance to Afghanistan. From 1980 onwards most of the health services were delivered through cross border operations and targeted at dealing with emergency situations. In this context, NGOs have been given considerable operational freedom on the ground, negotiating directly with local commanders and developing their own networks which grew separately from the local, weak or absent Ministry of Public Health (MOPH). Under the Taliban regime, NGOs acted as a main interface with the Taliban and the international community.

Following the 11^th September events in the US and the influx of donor resources, the number of NGOs has escalated, and so has the size of their operations, with considerable challenges posed by increases in resources, visibility and aid dependency. Services proliferated in response to the obvious health needs, the lack of resources and the government’s willingness to accept assistance.

Against a background of limited resources and highly fragmented health services delivery, significant effort in developing a Basic Health Services Package (BPS) is being invested by the MOPH. The objective of the BHSP is to organise health service delivery in a manner that provides adequate coverage and quality of health care to the population, especially in rural and remote areas. However most observers of present day Afghanistan would agree that it will take a considerable time to build up the implementation capacity of the central and local governments.

After the events of September, Afghanistan became a high profile crisis characterized by huge media attention and increases in available funds. In such a context, the health needs assessment phase has been challenged by pressures to expand the population coverage rapidly. In addition, the short project cycle encouraged NGOs to identify projects that could deliver visible outputs quickly.

The requirements of donors have indeed influenced the quality of diagnosis, but agencies themselves also share responsibility on the way the humanitarian response has been designed. As observed, new health interventions have not always been grounded in initial assessments of real needs. Because of the many fund opportunities offered to NGOs, some agencies bypassed needs assessment and started searching a project with resources readily available. Competition to "fly agency flags" first thus prevailed and anecdotal evidence suggests that this approach often had detrimental effects on previous NGO assistance in health. Many aid workers complained of disruptions to their established clinics each time NGOs without prior experience in the country rushed to the area without taking into account the ongoing activities.

This situation is particularly noticeable in urban areas which attracted a significant proportion of health interventions. For example, the fact that out-patient department (OPD) activities supported by two or three different organisations are running in parallel within the same hospital compound questions the appreciation of the importance of needs assessment and the wastage of efforts and resources.

The twenty years of war and the total breakdown of public services make prioritisation extremely difficult. The absence of other humanitarian organisations, the remote and traditionally under-served provinces and the overwhelming needs were the main reasons for agencies to embark on new geographical areas. Marginalized communities, such as Hazara ethnic group and vulnerable population in Internally Displaced Persons (IDPs) camps have been targeted by NGOs, although limitations in operational capacity and security challenges have severely constrained geographical coverage, especially in the Southern Region.

NGOs often refer to "huge needs" to justify their presence in an area. However, it is not clear what lies behind this term. Existing documentation at NGO level contains very little on the way assessments are undertaken. In most cases, agencies use the expatriate field staff in place. From the discussions with aid workers, the general approach to identifying needs tends to be quick and rough.

Very often the diagnosis of health needs and situations has been driven by NGO knowledge and competence. As a result, interventions, often based on an assumed need for health infrastructures, may underestimate the complex range of interacting needs, demands and expectations of providers, patients and communities. This was well demonstrated in the case of a remote 40-bed hospital, newly rehabilitated, with only one in-patient at the time of the visit and a continuous under-utilisation trend. Nonetheless, the needs assessment conducted a few months ago concluded that it was crucial to invest financial and human resources into the health facility. Did the assessment take into account the NGO expertise (e.g. "providing a hospital service") only? Were the constraints, local capacities and resources considered and analysed?

It is also worth mentioning, however, the concrete steps taken to address the high degree of somatisation often seen among patients. Very recently, some agencies have investigated beyond the rehabilitation of health structures, and have contracted experienced professionals to identify the specific needs in relation to mental health. During the course of the second mission, it will be interesting to see how psychological care can be implemented within the Afghan context.

In the urgency to respond and to meet the immediate needs on the ground, a top-down approach prevailed in which participation of beneficiaries has been negligible. In many instances, health activities were initiated with limited understanding of the coping strategies and demands of populations. Again, this raises the question of whether projects have been modelled according to aid packages, to NGO expertise or to the social dynamics of communities.

Several NGOs felt that the short time frame imposed by donors was incompatible with a participatory approach. Others reported difficulties to involve beneficiaries, because of their high expectations in terms of health infrastructures and resources. As many health staff noted during the discussions: "All they want is more clinics, doctors and drugs".

Only those agencies which did not scale up their previous activities allowed for time and preparation of new projects. By and large, they were able to identify real needs and to ensure some level of community participation, especially in the area of Traditional Birth Attendant (TBA) training and home visiting projects for ante-natal and postnatal care.

Life in Afghanistan is extremely vulnerable in the form of earthquakes, floods and drought. Assessment and analysis for the range of acute natural disasters have been impressive, especially for large-scale NGOs with expertise on emergency preparedness. Those agencies seem well equipped for both natural disaster and disease outbreak, including trained local teams, water storage and availability of first aid and trauma kits. Such expertise allowed for a rapid response at the time of the earthquake in Nahrin District.

Small-scale NGOs often lack experience in emergency preparedness. They tend to rely upon the bigger agencies, without necessarily benefiting from their expertise . For example, in a well-known area prone to earthquake, the needs assessment did not consider this factor, leaving the only health-related NGO unprepared for an emergency response.

In the Southern Region, regular drought assessments are being carried out by the major medical agencies. While emergency preparedness includes the stocking of therapeutic foods, partnerships for the monitoring of food distribution have been developed with the relevant UN institutions.

Overall the tendency has been to scale-up health service delivery operations, to employ large numbers of national staff and to become involved in new sectors, such as nutrition, without necessarily possessing the expertise. Agencies with previous involvement in Afghanistan gradually restarted their programmes and in most instances ventured into new geographical areas. Very few, especially those with a more developmental approach, came to a decision not to extend their interventions.

Constraints related to the increase in budgets and geographical coverage were often under-estimated. In many instances, scaling-up affected NGO’s organisational capacity and undermined the quality of interventions, as agencies had to struggle simultaneously with delivery of health services and building technical and internal capacity.

By and large, most of the projects visited were not really emergency assistance but the establishment of hospital and clinic activities with heavy reliance on a project-based approach. Despite the fact that many field situations are in a grey zone, lying somewhere in-between "non-emergency and non-development", the relief approach and the use of "emergency tools" still prevail.

Obviously short-term funding and the complexity of the field make it difficult for NGOs to determine strategic aspects, such as entry and exit strategies. In addition, many aid workers have limited experience in planning medium-term strategies. This can explain in part the lack of NGO-led strategy, and the fact that programmes suffer from a partial vision such that implementation tends to be shaped by day to day decisions.

This "flou artistique" is exacerbated by the fact that, since many years, medical NGOs have taken the entire responsibility for the provision of health services. The events of September 11^th have not changed this substitution role and to date, supporting health centres and hospitals is still seen as the main, if not the only, possible and desirable response in the health context.

Curative health posts, mobile teams and feeding centres, operating independently, dominate the health service delivery. Support remains physically scattered and structure-based with a focus on individual health facilities. This type of "standard" project is often characterized by a strong NGO identity ("we do a good job; the others don’t") and therefore functions with its own targets, staff, transportation, medical equipment and medicines, training programmes, supervision system and so on. In addition, as it matches the donor’s norms, funding has not been a main constraint.

While the NGO work takes place at micro-level, the macro-dimensions of the health sector and the relation between the strategy and context received little attention. Many health workers claimed that there were too busy. This is understandable in the current situation where major emphasis is placed on delivery of health services. Nonetheless limited conceptual thinking may create difficulties to frame an adapted strategy and criteria for assistance.

Until recently, neither the NGOs nor the MOPH had applied much thought to the problem of seeing how their work at micro-level could be used to inform and influence health policy and practice at macro-level. However, at the time of the mission, the performance-based partnership agreements (PPA) scheme, as worked out by the World Bank and donors, was generating considerable debate. Some NGOs were extremely concerned about the future of their work and strongly felt that the scheme, while outside their control, pushed NGOs aside. Others, while recognising the potential PPA disadvantages, agreed that the provision of health services across the levels of the health system lagged behind NGO capacity and required another approach .

The key issues which emerge are whether and how NGOs services can be integrated within the future health system. One of the major challenges will be to match the health response to the context and find the right equilibrium in a changing and volatile environment.

Although the health projects aim to reach specific target populations such as women and children, these groups are not always benefiting from the health facilities and preventive services remain often under-utilised, especially ante-natal care. In the Southern Region, populations have a different access to health resources because the complicated terrain and the unpredictability of the security situation have constrained NGO logistic capacity.

In discussions with the beneficiaries, the phenomenon of the ill travelling past the public clinic to get to local pharmacies or private practitioners has been widely reported.

The most frequent barriers to utilisation of public health services were described as follows:

• lack of transport
• distance and time to the clinic
• restricted opening hours
• long waiting periods
• poor quality of physical examination
• social restrictions on women’s mobility

In addition, it seems that the interactions between the health staff and the patients are quite poor. Surprisingly, the financial issues affecting access have not been raised although cost-recovery is implemented in various ways in a number of health facilities.

From the above, it is apparent that simply developing services far away from the villages is insufficient to address the current imbalance. Yet outreach initiatives that are strengthening linkages between communities and health centres are limited and will probably require significant time to develop. On a small scale, some agencies are participating to TBA training. Although the involvement of community health workers has been reported, the scope and monitoring of their work remain unclear.

The duration of the clinical encounter is short, with reporting consultation times of 5 minutes or less. This can be explained in part by the high demand on mobile clinics and OPD departments, which makes it difficult to provide good quality of care with adequate examination and explanation on the cause of illness, the treatment and its side-effects. In addition, the lack of privacy at the time of the consultation seriously questions the quality of the physical examination and the diagnosis.

The prescribing of inappropriate drugs, inadequate dosages, polypharmacy and the excessive use of injections have been commonly observed. Very often, modern health care treatment is equated with the administration of drugs: the larger the quantity, the greatest the variety and the more direct the treatment route, the better. However, the public health consequences of irrational drug use in terms of adverse effects, limited efficacy, antibiotic resistance and risk of infection due to improper use of injections seem overlooked.

In many projects, discrepancies between practitioner knowledge and practice were observed. Although Afghan doctors are aware of the correct course of drug management, they do not necessarily adopt it and recognise the influence of patient pressures. Obviously concerns about maintaining professional and social prestige as good physicians play an important role for treatment practices which are known to be harmful and ineffective.

In-service training interventions to improve health staff knowledge and skills, so as to reduce inappropriate dispensing, have proved popular among NGOs. Where harmful practices are driven by patient demand and community expectations, reinforcing strategies directed at these key groups are virtually non-existent. Overall, levels of user education and awareness play a limited role, except for the few projects that have established linkages with private pharmacies. However, in the absence of pharmaceutical regulations and enforcement mechanisms, most NGOs agree that a health education strategy will have a limited impact.

The educational messages as delivered at health facilities may also come into question. The health messages are not always adapted to the local reality and people’s ability to apply it at home is far from straightforward. Furthermore there is little evidence that the information, given in crowded and noisy settings at a time when the person is sick and has been waiting for long hours, can be easily retained.

The majority of respondents identified human resources as one of the most critical issues in project implementation. Working in a complex setting such as Afghanistan is seen as extremely demanding and requires an uncommon range of abilities. While the dedication of aid workers is impressive, low morale was also observed.

Short-term commitment (from 3 to 6 months) and high rate of aid workers turnover creates obstacles to lessons transfer and learning and institutional memory. Too often field-based projects are dependent on an individual’s drive that leaves after few months.

Recruiting experienced expatriate staff, especially in the medical and co-ordination field, is a major difficulty for NGOs. Health managers are often over-stretched by their responsibilities and the absence of leadership at the field level is likely to create a fragmented work lacking coherence, efficacy and a clear strategic vision.

For national staff, the most acute shortages are of doctors and midwives. The competition between agencies has had a detrimental effect on the recruitment of qualified staff (e.g. the poaching of staff, especially female gynaecologists and midwives). Furthermore, the restrictions on women’s mobility are a real disincentive for female health professionals to move to rural areas.

Although some NGOs made efforts to position Afghan health professionals at managerial level, the professional status of MOPH health workers, whose salaries are below subsistence level, remain problematic. Deregulation in relation to incentives still prevails and there is an unbalanced distribution of available health manpower, the majority being concentrated in big cities.

Over the last years, gender issues in Afghanistan have stimulated much debate. What is the work on the ground in practical ways to improve health projects?

At the health facilities level: Male doctors hold senior positions and health staff are disproportionately male, demonstrating that, up to date, women have made little inroads into the health structure. While most of the health projects are targeting women, maintaining appropriate levels of female staffing is critical for the delivery of such services. Although NGOs have opened up more possibilities for female health professionals, especially in the field of MCH and Emergency Obstetric Care (EOC), the number of nurses, midwives and auxiliary midwives at health facilities remains dramatically low.

As reflected in the field activities, almost every health project stresses the need to provide specific, women-focused health care interventions. However, the likelihood of their acceptance and implementation in the Afghan context remains a critical point if the adequate human resources are not available.

Overall most agencies are struggling to reduce the major imbalances in the gender composition of the clinics and hospitals but the competition between agencies to attract and hire qualified female staff, poses serious constraints to the health projects located in rural and remote areas.

At the community level: Women and men are also positioned differently in relation to health care services. Traditional, cultural and religious values in Afghanistan still require women to wear the Burqa. In particular, access to and utilization of health services are strongly influenced by the lack of freedom to act without permission from husbands or senior kin. Some informants also told that some men were reluctant to spend time and money on their wives’ health care. Moreover it is recognised that women have less access to income-earning opportunities and other resources, including health care.

Most agencies have established a working relationship with MOPH counterparts and local authorities. Efforts to rationalise the distribution of resources have been successful in areas where the MOPH had enforced meaningful co-ordination to direct NGOs to those areas identified as the most in need.

At provincial level, health co-ordination through formal mechanisms such as regular meetings is well functioning, although extremely time-consuming and placing extra strain on health managers. While meetings provide mainly for an exchange of information, effective co-ordination seems difficult.

The expansion in the number of NGOs and activities heightened the coordination challenge, as each agency came with its own assessment of needs, agenda and strategy for implementation. The major challenges obviously remain moving beyond the rhetoric of collaboration, on to planning how to implement it so that it results in the sharing of objectives, resources and expertise.

Some NGOs have developed a monitoring system whereby checklists are used to review the activities of the care provider and caretaker in relation to a sick child, immunization and antenatal care. However, it is often unclear how the collected information is analysed and fed into the decision-making process.

In most projects, qualitative indicators remain under-used. Monitoring focuses substantially on quantitative targets, with limited evidence that changes in health needs and priorities receive due attention.

At the micro-level, poor quality of diagnosis and treatment and high defaulter rates are best examples to stress that, despite data collection and the use of monitoring checklists, concrete actions are not always taken to tackle these issues. For example, over the past three years, provision of clean and safe water and sanitation in one IDP camp have been improved as shown by the presence of numerous hand-pump wells, collective showers and latrines. Alongside with general food distribution, supplementary feeding centres are specifically targeting women and children.

Despite these improvements, the monthly health reports show that the incidence of diarrhoeal diseases and malnutrition continue to be high. Did the target groups utilise the services that the project offers? How did they use them? Did they benefit directly from the water supply and the food distribution? This situation illustrates the gap that exist between the information collected and the analysis of the many activities so that potential corrective action can be made.

This comment also reflects the certain level of fatalism, as expressed by many health workers, when faced with recurrent health problems. The field reality and the difficulties attached to it could partially explain the missed opportunities for taking into account the changing needs and the reasons why some activities are hardly amenable to changes.

Although health projects are too scattered geographically to have a significant impact beyond that of the individual project, many have positive accounts:

• the risk of disease outbreak has been reduced;
• health activities have been instrumental in creating a sense of routine and progress for national and local authorities;
• the existing network of clinics and hospitals and the provision of medical equipment and medicines are key elements in giving local populations a sense of confidence that there are infrastructures and resources in place to deliver health services and to rebuilt trust in them;
• working for NGOs provides health professionals with an economic outlet not available to them otherwise. By enabling MOPH staff to access a monthly living wage through incentives, NGOs create also an environment conducive to normal daily activities whereby health staff are given the opportunity to improve skills through training and supervision;
• NGOs have pioneered some important activities, such as early experiments with cost-recovery and training of TBAs.

Four overriding themes are emerging from this first mission and illustrate the critical aspects of the quality of health interventions in Afghanistan. The first concerns the neglected areas of needs assessment and monitoring. Scaling up, donor pressures, added to the fact that health staff in the field do not always recognise the importance of comprehensive assessments and adequate monitoring, are main limitations to the quality of the health actions.

The lack of human resources, both international and national, has been a recurrent theme. In addition, the imbalances in terms of gender and in the distribution of labour pose serious constraints to most projects located in rural and isolated areas.

The third theme relates to the contrast between the significant inputs invested in terms of time, energy and resources and the real level of outputs delivered at health facilities. Since last September, NGOs became a mechanism to increase implementation rates. But in practice, was this inflation detrimental to quality processes? What difference did the activities make? How did the various inputs translate into intended results?

Finally, the fourth theme is to do with the dependency on the institutional logic of the funding system in high-profile situations: how can health interventions be safeguarded against competition and pressures to spend the funds quickly? What strategy should be adopted in order to ensure that the programming of good health projects is not jeopardised and that it relates to the wider dimensions of the Afghan context and to the new health policies?

1. The following chapter is the report of the Quality Project mission for the nutrition sector. The nutrition sector is defined as covering "actions aiming to improve access to a balanced ration, in quantity and quality, by covering deficits without engaging production and exchange activities"; the latter are addressed in the chapter on food security and agriculture. In order to analyse certain issues in greater depth, more attention was paid to feeding centres in this report. Issues concerning food aid, which constitute an important part of nutritional interventions in Afghanistan, will be more fully addressed in the following missions.

 

2. Following the events of September 11^th, resources available for emergency and reconstruction programmes in Afghanistan greatly increased. The scale and coverage of food aid and nutrition interventions thereby increased and investments in capacity-building of the Afghan government were made possible. While at the national / policy-making level long-term strategies to build the government’s capacity on malnutrition are being worked upon, in collaboration with NGOs, UN agencies, donors and universities, at the field-level, interventions still tend to be NGO-led and relief-oriented, with short to medium-term perspectives (e.g. SFCs and TFCs), partly because of the continuation of distress situations (conflict areas, drought, returnees, IDPs).

 

3. In a context of competition between agencies to "fly their flags first" and of urgency to respond to the drought and effects of the conflict, time was often scarce to conduct needs assessments.

The limits of nutritional data – in a context of low acute malnutrition with high food insecurity – are being recognised, and the need for pertinent food security indicators and qualitative data emphasized. However, the practice seems to be that nutritional surveys are still being carried out, with unclear objectives, and not always successfully. Pressure from donors to have quantitative data was mentioned as a key factor, while the pertinence of anthropometric data as a means to identify needs and ways of responding to them is questioned. Aid workers emphasize the need for more qualitative data. A focus on quantitative, technical, information may indeed contribute to perpetuating a top-down, technical approach to malnutrition, leaving little space for consultation with the Afghans concerned.

 

4. In terms of programme design, the apparent tendency is to implement "blue-print" programmes, according to a standard format (e.g. SFCs) with little discussion as to their pertinence and effectiveness in each context. This raises questions as to whether programmes are designed according to the needs and local situation, according to agencies’ mandates and technical expertise or donors’ agendas and preferences. The shortage of staff with nutrition expertise and knowledge of the Afghan context, along with the uncertainties in the present political and humanitarian situation, contribute to making it difficult for agencies to step away from standard responses.

Given the difficulties faced in the implementation of therapeutic feeding centres, agencies are resorting to the distribution of Ready to Use Therapeutic Foods (e.g. Plumpy Nut) for use at home, with little or no monitoring, though the effectiveness of these products is not yet proven outside TFCs and in the absence of regular supervision. This raises both practical and ethical dilemmas.

 

5. The difficulties faced during programme implementation may be related to the tendency to implement standard responses, that may not be adapted to the local context. High rates of defaulters, low weight gains, low rates of cured, may point to the fact that SFCs, in particular (though they can be way to gain access to women and provide them with health education), may not be an appropriate response, especially in rural areas, where the population is very dispersed and difficult to access.

 

6. Monitoring, when it is done, tends to focus on programme results and to be essentially quantitative, with little consultation of beneficiaries. Monitoring data does not seem to be always used to inform decisions concerning the evolution of strategies, with some agencies continuing programmes that yield poor results, without reviewing the potential reasons. Inter-agency use of monitoring data is made difficult by the need to coordinate the data collection, compilation and dissemination, which itself is time and effort-consuming.

 

7. It must be emphasized that investments made to address the causes of malnutrition through nationwide and long-term strategies represent a considerable improvement compared to a 15 months ago, when only a handful of nutrition projects were running, scattered throughout the country. Finally, the concerns and questions outlined here were raised by aid workers themselves, thereby showing their determination to improve the quality of their actions, a process to which the Quality Project hopes to contribute.

Malnutrition can be defined as "a reduced food intake in relation to a recommended dietary intake". The definition is simple, yet nutrition is at the heart of a vast field, at the cross-roads of several domains, including health, food security and water and sanitation. In order to define the limits of this chapter and of the sectors of activity that were analysed, it was decided that this chapter will address exclusively nutritional interventions, which are defined as: "actions aiming to improve access to a balanced ration, in terms of quantity and quality, by filling deficits, but without going into production or exchange activities", the latter being addressed in the chapter on food security and agriculture.

In order to analyse certain issues with greater precision and in greater depth, the following choices were made :

• The report focuses on the field level (rather than on the national / policy-making level), since the main objective of the Quality Project is to improve the quality of humanitarian interventions in the field.
• During this first mission, more attention was given to feeding centres because their implementation raised many questions which were considered important to address in detail. Food distributions (in their various forms : general distributions, targeted distributions in urban programmes, food-for-work programmes, etc.) represent an important part of the nutrition sector which is not analysed specifically this report. The questions concerning food distributions are nevertheless covered in the Quality Project, and will be addressed more fully in the following missions.

The country has been undergoing years of conflict, drought, and population displacements; it has seen a degradation of its infrastructure (irrigation networks, roads, bridges, etc.) and of the institutions and services supporting the productive and trade sectors. Though these facts are clearly established, the food and nutrition situation remains poorly understood:

On one hand, a number of indicators suggest that rural livelihoods are in crisis: households are experiencing production deficits (low agricultural yields, low irrigation capacity, low household stocks), and there is a degradation of the economic situation in rural areas as indicated by the growing indebtedness, the acceleration in the selling or leasing of cultivable land, the reduction in livestock, and phenomena such as the increase in land surface used for poppy cultivation.

On the other hand, anthropometric data show a quite striking pattern :

• Rates of acute malnutrition are surprisingly low (between 2 and 10% of global acute malnutrition, including 0.5 to 2% severe cases) given the high levels of food insecurity in some areas. Acute malnutrition is usually associated with morbidity (e.g. diarrhoea and ARI) and/or poor caring & feeding practices (e.g. early weaning and improper weaning foods).
• Rates of chronic malnutrition (stunting) are very high (between 50 and 60% in most areas). These high rates are associated with micronutrient deficiencies (e.g. scurvy epidemics, anaemia, goitre), which are due to a very poor diet diversity, compounded by the years of drought.

Though acute malnutrition rates are not alarmingly high (compared to rates of 20 to 40 % sometimes found in African crises), the situation is nevertheless critical, since high rates of chronic malnutrition and micronutrient deficiencies increase individuals’ vulnerability to disease and death. Furthermore, though food insecurity does not seem to translate in high rates of acute malnutrition, it leads to severe social, economic, and physical stress for families.

"Many nutritionists have experience of Africa. But patterns of malnutrition are very different here. We have to dispel the attitude ‘what would we do if it were Africa’" nutritionist, Mazar-I-Sharif

In general, nutrition activities at the field level are still very much project-based, sometimes with a regional approach, and still tend to be relief-oriented activities (with short to medium-term perspectives).

Food aid programmes are diverse. They include: general distributions of dry rations aiming at a wide coverage of food needs in severely affected areas; distributions of dry rations targeted according to specific criteria; and food-for-work projects. It is important to bear in mind that these types of programmes have been implemented for years in Afghanistan, where they have taken on very different forms, depending on the place and time. It must also be noted that they involve considerable quantities of goods that need to be transported in often very difficult logistic conditions: mountainous terrain, insecure areas, snowed-in passes, etc.

The distributions that are currently carried out in Afghanistan tend to correspond to one of the four following types of responses :

• drought response, in the most severely affected zones
• assistance in IDP (Internally Displaced Persons) camps in the different areas where the drought, exactions or conflict may have forced people to flee
• return assistance, for returning refugees, and, to a lesser extent, for returning IDPs;
• support to specific vulnerable groups, such as "displaced women in Kabul".

Centres where a porridge mix (usually Corn or Wheat Soya Blend –CSB or WSB–, with oil and sugar) is distributed for children suffering from moderate acute malnutrition; these centres are often integrated in Maternal and Child Health (MCH) programmes.

The treatment of severe acute malnutrition is provided in hospitals, in day care centres, or through the distribution of Ready to Use Therapeutic Food (e.g. Plumpy Nut or BP100) with or without monitoring.

The two latter types of activities can also serve to implement other types of programmes that require regular gatherings of mothers and children :

• health and nutrition education (in SFCs, TFCs and clinics)
• nutrition surveillance (nutritional surveys, nutritional surveillance in clinics)
• implementation of preventive or curative measures (vaccination, deworming)

The recent political changes in Afghanistan have made it possible to move towards more "development-oriented" strategies, as seen at the national level, that address the complex structural issues underlying malnutrition. However, it will probably take time to go from mainly NGO-led, relief-oriented interventions to long-term, Afghan-led strategies, especially since in many areas, the humanitarian situation (IDPs, returnees, drought-struck areas) still call for relief operations. There are close collaborations between various actors (Afghan authorities, UN, and NGOs –local and international) to work on this transition, but it will take time to see its effects in the field, as there are still many uncertainties in Afghanistan’s future.

Before September 11^th 2001, few NGOs were implementing specific nutrition interventions, and relatively little anthropometric data on nutritional status were available, especially in rural areas. The events following September 11^th and the international focus on Afghanistan led to a recognition of the seriousness of the humanitarian situation, especially with regards to the ongoing drought, and to a massive arrival of donors and NGOs.

These had two positive consequences:

• an increase in the scale and coverage of emergency interventions (notably food distributions, opening of supplementary feeding programmes) in drought-struck areas and for IDPs/returnees.
• An investment in the establishment of long-term policies and strategies to address malnutrition and in the capacity-building of the new Afghan government on nutrition, health and food security issues.

At the national / policy-making level, nutrition issues have been placed under the responsibility of the Ministry of Public Health (MoPH), with expert technical support from UNICEF and Tufts University. Since malnutrition is also closely related to food security and sanitation issues, there is a close collaboration with ministries and agencies involved in these sectors, such as the Ministry of Agriculture (MoA) and Ministry of Rehabilitation and Rural Development (MRRD), UNICEF, WFP, FAO, WHO, etc.

At this level, the focus is rather on long-term policies and strategies, aiming at the development of a national capacity to address malnutrition problems in Afghanistan. The issues addressed include:

• capacity-building of MoPH on nutrition (especially training activities)
• inter-sectoral policies on the prevention of Micronutrient Deficiency Diseases (MDDs) and improvement of diet quality
• National Food Security and Nutritional Surveillance
• Nationwide health and nutrition education campaigns (e.g. breastfeeding campaigns)
• Technical support to implementing partners (e.g. development of best practice sheets)
• National policy for capacity-building in the management of severe malnutrition

At the implementation / field level, NGOs were found to be the main actors. The types of programmes they implement are those presented in paragraph 2.2, above.

The political situation in the autumn of 2001 was such that most international aid agencies did not have access to the field until late November 2001. The context of aid, with high donor pressure to act fast, and competition between agencies for funds and to "fly agency flags" first, was such that it limited the time taken to do needs assessments and coordinate activities. The reports of the drought and the scale of refugee return movements accelerated the sense of urgency. This led to many programmes being designed without in-depth field assessments, proposals sometimes being written from Pakistan, Uzbekistan, Iran or in agency headquarters. In other cases, rapid assessments were carried out as soon as agencies had field access.

Other factors may have limited the depth of needs assessments: the arrival of new agencies in Afghanistan, which had little knowledge of the social, geographical and political context, and did not have an existing logistics capacity in the field; the lack of experienced and qualified human resources; the tendency to use "blue-print", or standard, programmes, which can sometimes determine (and limit) the methods used for assessments and the type of information collected (see section 4.1).

The nutritional assessments that were carried out generally involved one of the following methods:

• rapid assessments using the Mid-Upper Arm Circumference (MUAC); this type of evaluation is not recommended since this type of data is less reliable than weight-for-height data, but it is useful when there are staff, logistics, and time constraints.
• nutritional surveys (taking of weight-for-height data in a sample of children under 5 years of age –the 30 cluster method is considered the most reliable- sometimes including mothers’ measurements).
• collection of nutrition information (qualitative data, observations, anthropometry) integrated in food security or health assessments or programmes.

Programmes seen tended to be open either after a rapid assessment showing some level of malnutrition (sometimes complemented by information on the food security, health, and/or water and sanitation situation), or as a part of MCH activities, without necessarily doing a specific nutrition assessment (malnutrition cases are likely to be seen in most health centres, since malnutrition is often associated with disease). Nutritionists, or staff working on "classic" nutrition activities, were seldom accompanied by agro-economists, or food security specialists, from the outset of a programme (i.e. needs assessment phase). This may represent one of the reasons for the lack of pertinence of certain nutrition interventions seen.

In general, anthropometric data (malnutrition rates expressed according to the weight-for-height ratio or MUAC) are considered a key tool for assessing the nutritional situation and vulnerability to food insecurity. In Afghanistan, however, the low observed rates of malnutrition have led aid workers involved in nutrition to recognize that anthropometric data (and nutritional surveys in particular) should play a limited role in monitoring vulnerability, in this context.

The main reasons presented for this include the following:

• malnutrition rates present the symptoms rather than the causes of vulnerability, and are often a late indicator of any deterioration in the situation
• the need to collect complementary information to be able to interpret malnutrition rates
• the high use of resources needed to conduct nutritional surveys (time, staff, logistics)
• the need for trained staff to analyse the data
• the delays between the data collection and the dissemination of reports often rendering findings out-of-date by the time they come out

The Food Security and Nutrition Surveillance working group proposes to limit the role of nutritional data to confirming observed deteriorations in food security indicators. The main objective of nutritional data was emphasised as being that of monitoring trends rather than obtaining a prevalence, and to provide more information on the links between malnutrition and food security, feeding/caring practices (weaning, breastfeeding, etc.) and morbidity. The methods advocated for these purposes include nutritional monitoring in sentinel sites, with 30x30 cluster surveys, only being done when there is a change in trends.

"We encourage surveys where it is possible, when a NGO has the capacity. But a survey is not good just for the sake of it. We need other indicators.(…)Sometimes, they [surveys] are not necessary." nutritionist, Kabul

As illustrated by the recommendations of the Food security and nutrition surveillance working group, much efforts are done to improve the technical implementation of surveys, and to ensure they are done at the appropriate time, with appropriate objectives. At the field level, however, it seems that nutritional surveys are still often carried out, with varying objectives and methodologies, in various contexts, and including by agencies and staff that do not always have the expertise or capacity to successfully complete all the stages of a survey. In response to this problem, a standard methodology was prepared by UNICEF and the Centre for Disease Control (CDC) to standardise the implementation of nutritional surveys across agencies and to assist NGOs with little technical expertise on surveys. Though very thorough on a technical level, this method was considered by some as too complex or burdensome, and some agencies faced considerable difficulty collecting, entering and analysing all the data collected with this methodology, thereby causing further delays in the dissemination of the data.

"It seems that some people just get a nutritionist, and do a nutrition survey, without it being clear why." Nutritionist, Northern region

This could suggest that despite the decision to give a limited space to nutritional surveys, in practice they are still very time, energy and resource expensive. It indeed takes time to bring policy to the field, especially when there is a lack of field staff with technical expertise in nutrition and food security. But other factors may be at play. Pressure from donors to have reliable quantitative data was highlighted as contributing to the persistent importance given to nutritional surveys. Conducting a survey may also be perceived as conferring a certain professionalism to an agency, though agencies do not always have the capacity to undertake one, nor the experience to assess when and how a survey may be the most appropriate type of assessment. Paradoxically, the promotion of the standard survey package may not be simplifying the use of nutrition techniques, but encouraging the use of complex methods which may not always be the most adapted to assess and monitor needs.

"Surveys were useful because we got good information on health and mortality; they were useful to point us in the right direction.[…] But are we reinventing the wheel if we keep on doing them?" nutritionist, Northern region

This report in no way denies the importance of nutritional surveys that have been carried out, nor the necessity to have precise and reliable information on the nutritional status of a population. But in the current Afghan context, and considering the situation in the field, the following question can be raised : how many surveys must be done, and are they always justified when they are carried out? Would other types of assessments (e.g. socio-economic surveys, household food consumption surveys) represent a more efficient and pertinent use of resources and time?

Another question that may be raised is that of how anthropometric data are used, in terms of programme and strategy design. One can observe, by reading nutritional assessment reports, that programme recommendations tend to be similar, whether the malnutrition rate is 3 or 10% ("implement water and sanitation programmes", "carry out a food security assessment", etc.). The recommendations are based essentially on qualitative data that may have been collected in parallel (though this is not always the case), and without which malnutrition rates cannot be interpreted. Do anthropometric data always truly contribute to the needs assessment and the design of programmes, relative to the costs (in time and resources) they involve ? Are they sometimes used to justify a posteriori a strategy that has already been established? To provide quantitative data for proposal writing? Or are they really used to inform decision-making?

"The next time, I will go back to the field with smaller teams and speak with the people. I’d have list of issues in mind but no set questionnaire, and we’ll see where the discussion takes us" a nutritionist having just completed a nutritional survey.

These questions are not meant to suggest that anthropometric data are irrelevant in all cases, but are laid out because they were not always raised by concerned agencies. Many aid workers emphasize the need for more qualitative information, and many agencies are working towards this, but the practice still tends to focus on quantitative information (no doubt prompted by donor institutions). Such pressures probably strengthen the tendency to have a top-down, and highly technical approach in responding to people’s needs, which may be far from the Afghans’ own perception of their needs and how they can be addressed.

It seems that there is little, if any, consultation of potential beneficiaries, in particular mothers, in nutritional assessments. There is little information on how mothers perceive their family’s needs in terms of health and nutrition. Nutrition messages, for example, can be designed without knowing which foods are available to mothers. If information is collected on feeding practices or a child’s health status, it is most often in the form of questionnaires rather than of open discussions.

Malnutrition is measured essentially according to weight-for-height (expressed in percentage of the median or in Z-scores), a concept foreign to most people outside the nutrition sector. During nutritional assessments, for example, one can understand that a mother be surprised to see 4 hurried women rush in her house, with scales and measuring boards, choose a child at random, undress it, take its measurements (often amidst cries and struggles), and leave, with little (if any) explanation concerning the reasons for these strange practices. Where surveys are repeatedly carried out, some families, who do not see the link between the survey and a potential intervention, sometimes even refuse to let the survey teams enter their homes.

"What do you mean my child is 81% ? Look, he is malnourished, he is under 80%! " a Hazara mother who has perfectly understood the weight-for-height criteria for admission in a feeding programme, Parwan Province.

The application of these techniques and of highly technical criteria may make it difficult to engage in a dialogue with mothers that makes sense to them, and that generates a space for trust, which is probably necessary when addressing issues that are at the heart of a family’s intimacy (sharing and preparation of food within the household, breastfeeding, child and maternal health, etc.).

Aid workers mentioned several constraints to consultative processes: the short funding time frame imposed by donors, difficult access to women, the raising of expectations, and the exposure to ongoing demands one may not be able to respond to. But given the need for more qualitative data is recognised, and in the context of more long-term policies on mother and child care, it is hoped that more space will be given to the consultation of local populations and to participatory approaches.

The strategy in many of the nutrition programmes seen did not clearly stand out. The impression given was that some nutrition techniques are applied in a rather standard way, with no thorough reflection concerning the programme’s evolution or its appropriateness. The number of SFCs, for example, greatly increased throughout the country (around 150 SFCs), though questions are raised as to their pertinence and efficiency in the Afghan context.

"The people say they don’t want the supplementary rations, they say ‘bring us a clinic, medicine, water’" aid worker, Central Highlands

This raises the question of whether the nutrition programmes are designed according to the needs or according to agencies’ mandates or their capacity to apply standard techniques, and/or the ease of finding funding for certain types of programmes. The shortage of experienced staff with nutrition training and knowledge of the Afghan context, the uncertainties in the present situation, and the lack of qualitative data in needs assessment also make it difficult to step away from standard responses.

The main objective of supplementary feeding centres is to prevent severe acute malnutrition by treating moderate acute malnutrition, when rates of acute malnutrition are alarming. But in the present Afghan context, the link between needs assessments and the opening of feeding centres is not always clear. Indeed, most nutritional assessments show quite low rates of acute malnutrition, but these are nevertheless used to justify opening feeding programmes (e.g. 5% of global acute malnutrition using MUAC). Of course, the level of food insecurity is often very high, and low rates of malnutrition in a large and concentrated population (e.g. in urban areas or camps) can signify a large number of potential beneficiaries, but this does not say whether supplementary feeding is the most adapted and efficient solution to malnutrition (see section 5.1) in the Afghan context.

Reasons evoked for opening SFCs included:

• As "Safety nets": before the international community had access to Afghanistan in autumn 2001, there was little information on, and much concern about, the effects of the drought, conflict and population movements in terms of malnutrition. Preparations were therefore made to implement SFCs as soon as field access would be possible (proposals written, stocks of porridge mix pre-positioned, etc.). The choice of this approach was partly the result of the difficulties faced in attempts to diversify the general food rations distributed through food aid programmes.
• As an entry strategy in a region: feeding centres are open in a region where an NGO wants to initiate activities, sometimes with an intention to elaborate a more subtle strategy at a later stage. The question was raised, however, whether the use of SFCs as an entry point does not entail unfavourable consequences for potential future programmes and approaches in the region (see section 4.4), by creating certain habits, establishing a kind of aid dependency, etc.
• As a response to malnutrition cases seen in medical programmes, a supplementary feeding component is added to a medical programme; or an SFP is automatically included in routine MCH activities.
• For specific target populations, such as IDPs, camp populations, etc. (though in these cases the resident population is often included in the programme, since it is common for there to be no difference in the malnutrition situation in the resident and displaced or camp population).

The efficiency of SFCs in terms of preventing severe and treating moderate acute malnutrition is questioned, in Afghanistan, as well as in other contexts. But SFCs may be used to fill other objectives: they are a means to maintain a nutritional surveillance over a region (through the screenings of children and admission rates), to screen for severe malnutrition cases, to provide health education to mothers, to integrate mothers and children in a health referral system when associated to MCH centres, and to ensure measles vaccination, deworming and iron and vitamin A supplementation. SFCs are also a way to gain access to women, who may be more easily allowed to leave their home if they obtain a food ration. However, these benefits are not always seen, especially in rural areas where the coverage of centres tends to be very low, or if the monitoring of patients is not thoroughly carried out, and where there are no therapeutic feeding centres or hospitals to refer severe cases. Furthermore, these objectives could be reached through other approaches. This is why it seems important to assess whether SFCs are the most pertinent solution to malnutrition issues, or whether alternative strategies may be more appropriate.

Alternative strategies may be diverse, according to the context: diversification of the food ration, increase of the coverage of general food distributions, support to agricultural or economic activities, water and sanitation programmes, community health projects, etc. To explore these alternatives probably requires one to go back to an analysis of the causes and context, as well as to reach a greater understanding of the needs, based on more qualitative information. These investigations and the design of alternative programmes would surely require greater creativity, and therefore more experienced teams, than those necessary for the implementation of "classic" SFCs.

For the treatment of severe malnutrition, the current most appropriate form of treatment is in an inpatient therapeutic feeding centre (TFC) where patients receive therapeutic milk and medical treatment. Given 24hour care is often difficult to ensure (e.g. when mothers are not able to leave their home a long time), treatment is also provided in day care centres, that are open all day (8pm to 4pm) or half a day (8am to 1pm).

However, these programmes are difficult to implement due to the lack of NGO experience or capacity on severe malnutrition, lack of qualified staff, logistic difficulties, remoteness (for the agency), distance (for beneficiaries). Furthermore, the rates of severe malnutrition are often low (1 to 2%) meaning that the number of beneficiaries and coverage rates would likely be low, especially in rural areas where populations are very scattered. Due to these considerable constraints, few NGOs are actually implementing therapeutic feeding programmes.

However, the importance of building local capacity –of the MoPH in particular– to treat severe acute malnutrition is emphasized. In this sense, the work of NGOs who are implementing TFCs is valuable, due to the continuous training and facilities they provide to health staff. Much work is being done to expand the availability of this treatment to other