Memorandum submitted by Merlin
ABOUT MERLIN
Merlin is the only UK specialist agency, which
responds worldwide with vital healthcare and medical relief for
vulnerable people caught up in natural disasters, conflict, disease
and health system collapse. Merlin's vision is of a world that
provides basic health care for all; which responds immediately
to save lives in times of crisis and which safeguards long-term
heath. Merlin's contribution is to act in times of acute need
whilst working to ensure access to health care in the longer term.
The aim is to ensure that vulnerable people in particular, who
are excluded from exercising their right to health, have equitable
access to appropriate and effective healthcare.
This aim is inspired and underpinned by the
World Health Organisation (WHO) declaration[104]
that the enjoyment of the highest attainable standard of health
is one of the fundamental rights of every human being without
discrimination of race, religion, political belief, economic or
social condition. In support of this aim, Merlin works in partnership
with global, national and local health agencies and communities
to strengthen health systems and build community resilience to
better prevent, mitigate and respond to health outcomes.
ABOUT MERLIN
IN AFGHANISTAN
Merlin was one of the first NGOs to enter Kandahar
in 1993-1994 following the fall of this city to the Taliban. Since
then, Merlin's health activities have included implementation
in southern, western, northern and northeastern provinces.
Currently Merlin is working in the three northeastern
provinces of Kunduz, Takhar and Badakshan implementing a range
of health-related projects including health service delivery and
community midwifery education projects. Currently Merlin Afghanistan
has a budget of close to $5 million/year (receiving funds from
USAID, EC, UNFPA) and employs 600 staff across three provinces.
Merlin works in direct partnership with a large local Afghan Non-Governmental
Organization (Care of Afghan Families—CAF) and is a member
of various NGO coordination bodies and technical fora within Afghanistan.
This abbreviated response focuses on a few key
areas highlighted by the Inquiry's Terms of Reference and in addition
Merlin is happy to provide a verbal submission to the Committee
if needed. The contribution is based on the experience and opinions
of an organisation working within the health sector and is also
limited in its relevance to the south of Afghanistan, due to the
sizeable consolidation of Merlin's activities over the past 4-5
years in the northeastern provinces.
DFID'S OBJECTIVES
IN AFGHANSTAN
DFID has committed to provide predictable funding
to Afghanistan over a 10 year period—through its development
partnership agreement with the Government of Afghanistan (GoA)
signed in January 2006. The priority focus of the partnership
has been identified as building an effective state. Fifty per
cent of DFID funding is going through the budget of the Government
of Afghanistan with the intention of moving towards Poverty Reduction
budget support or other forms of direct support. Whilst the relevance
and importance of direct funding for state building, strengthening
of governance and state capacity initiatives is not in doubt,
the available data suggests that DFID does not have any major
targeted focus upon the health MDGs. It is our understanding that
recent funding provided by DFID for health sector support is not
for direct service implementation but rather for areas such as
administrative reform/payment of Ministry of Health salaries.
In addition DFID support to other line Ministries including the
Ministry of Finance may yield funds for the health sector in the
longer term (ie through improvements in revenue collection).
Funding for the health sector is currently allocated
through donor commitments from USAID, EC and WB and while a reduction
in infant mortality within Afghanistan has been seen in recent
years, this is against a very low baseline in terms of infant
and child health. It is widely accepted that Afghanistan is off-track
on all the MDGs but given the importance that health plays in
the MDGs and the targets that have been set in the recent draft
National Health and Nutrition Strategy document to reduce maternal,
infant and child mortality, it would seem imperative that even
if DFID does not position itself to provide additional specific
funding to the health sector at this time, that it continues to
maintain a close eye on the adequacy of donor coordination, funding
and strategy to the sector and utilises its influence where appropriate
to ensure that health remains a priority issue overall.
COORDINATION OF
THE MILITARY
AND DEVELOPMENT
EFFORT
Merlin has extensive direct experience of working
in the north of the country—which is relatively stable compared
to the south—and where neither Merlin nor its staff are
seen as primary targets for insurgent activity. However the area
has seen a stepwise increase in criminal behaviour over recent
months and a worsening of the rule of law. A significant number
of attacks have taken place against military, police, civilian
and NGO persons.
While Merlin recognises that the north is less
polarised (between government and insurgency groups) than the
south and therefore provides an environment in which it is easier
to maintain impartiality of action vis-a"-vis its humanitarian/development
objectives, it also believes that aligning reconstruction efforts
with the military (as has happened in the south) is counter-productive
for the achievement of longer term development goals.
Our experience is that at a provincial level,
Afghans expect the military to guarantee security whilst other
bodies—especially the Government of Afghanistan and to a
lesser extent NGOs—should provide service delivery/assistance.
The Provisional Reconstruction Teams (PRTs) in particular may
confuse the separation of roles between NGOs and the military.
It is our judgement that short-term development projects implemented
by the military are unlikely to yield any form of security guarantees
for the military and that greater emphasis on informing the population
area about the wider objectives of the military mission of foreign
troops in Afghanistan would be more productive. It goes without
saying that reducing civilian casualties of military engagements
is also likely to have a positive benefit in terms of the populations'
perceptions of the military presence.
POSSIBLE TENSIONS
BETWEEN THE
DEVELOPMENT AND
THE SECURITY
AGENDAS
Merlin's experience shows that direct military
initiatives focused on development can in fact undermine longer
term recovery efforts due to the short term approach adopted which
often emphasises construction or one-off activities (eg vaccination;
one-off supplies or short term projects) and the lack of coordination
with wider government or donor plans.
Merlin has developed its own model of effective
health delivery based on its experience of working in an insecure
environment—which involves both greater community buy-in
as well as maintenance of a distance from the military. This is
not because the population majority in the north of Afghanistan
are in any way unreceptive to foreign troops, but rather because
a small minority of the population who are intent on destabilising
the northern region are more likely to target NGOs with links
to international military forces.
By way of example, for Merlin to become involved
in the reconstruction effort in the south would require a significant
shift in means of action and in particular developing a much sharper
distinction between humanitarian goals and its current posture
as implementer (on behalf of the Government of Afghanistan) of
health services. Intervention by Merlin in the south would entail
a much greater risk to expatriate and local Afghan staff who might
be employed by Merlin and would necessitate adoption of a position
of extreme neutrality—much as that adopted by the International
Committee of the Red Cross—and the firm backing of non-Afghan
bodies eg UK government as well as the GoA in order to allow Merlin
to directly negotiate humanitarian space with the Taliban and
other insurgent groups. It remains to be seen whether some of
these changes in modus operandi might yet be required within the
north, in the future, if security deteriorates to a significant
extent within the northeastern provinces.
THE ROLE
OF NGOS
The role of NGOs has proved pivotal in the re-development
of social services in Afghanistan. Sectors within which NGOs form
the delivery vehicle are amongst the most cost-efficient, output
effective of all projects currently funded through donors (Basic
Package of Health Services, National Solidarity Programme). However
the role of NGOs is and should be broader than service delivery—NGOs,
both international and local are a critical part of civil society.
Merlin's work in Afghanistan has been in conjunction with a local
NGO, Care of Afghan Families. Merlin feels that this international/local
NGO partnership provides the strongest "model" for building
local capacity amongst Afghans, ensures a more sustainable outcome
and should be supported in the longer term.
Currently Merlin is working with CAF in support
of the Basic Package of Health Services (BPHS) covering both primary
and secondary health care facilities. Merlin is directly responsible
for all aspects of management (financial, administrative) and
technical modelling across over 60 health facilities and soon
over 350 health posts. This support is providing direct health
provision to an estimated 1.1 million people in two provinces.
Despite the immense scope of actions of NGOs
within the country, the role of NGOs is circumscribed by current
donor-driven funding arrangements. Opportunities to extend service
delivery programming to encompass fields such as governance in
the health sector is limited due to the rigidity of current funding
mechanisms.
It is our opinion that the important role of
NGOs in support to the health service in Afghanistan needs to
be fully recognised and supported, especially in the important
transition to greater national ownership. This requires further
funding to develop the scope and range of their activities, based
on the observation of their success in implementation of the BPHS
and NSP national programmes. This is not to argue against the
importance of channelling funding through the GoA but instead
to lobby for a nuanced balance of support to both Civil Society
Organizations as well as central government.
The current security situation affects the ability
of NGOs to deliver effective programming, limits the opportunities
for staff recruitment and has transactional consequences upon
security budgets (which are not currently allowable under the
grants that Merlin receives) and thus has consequences for their
work. While there are extensive rules governing expatriate staff
security in country, these do not extend to local NGOs or local
staff who are in similar if not more dangerous positions. In many
cases the outcomes (of targeting or kidnapping) are worse for
national NGOs and staff. Merlin currently employs five expatriate
staff in Afghanistan but 650 paid local staff and therefore security
initiatives must take into account the balance of the NGO workforce.
Any security agenda must take into account the vulnerability of
NGO staff and any risks that might arise from closer alignment
of the development and security agendas. Protecting and maintaining
the development initiative is of course vital in order to satisfy
the needs of the population as regards humanitarian and development
needs—and furthermore in order to reassure the population
that the overall direction of the international effort within
Afghanistan is to both address development goals as well as provide
security assistance.
HARMONISATION AND
CO -ORDINATION
OF THE DONOR
RESPONSE
The current funding via the Afghanistan Reconstruction
and Development Fund is well received and provides a good model
for donor coordination. Channelling of donor funds through the
Afghan Government is to be welcomed but needs to be subject to
the same tests of efficiency and effectiveness as other modes
of expenditure of donor funds.
It is however apparent that there is increasing
emphasis being placed upon links between Foreign Ministries and
Development Ministries of many foreign governments which currently
have forces within Afghanistan under a UN/NATO mandate. Those
countries which do not have military forces within Afghanistan
seem instead to have a greater capacity to engage in a wider response
to humanitarian and development needs eg JICA. Countries which
have greater troop presence are being placed under increased pressure
to allocate development funding in line with political and military-protection
strategies—using the civilian arms of PRTs as "development"
agencies. An exaggeration of this funding strategy will have long-term
consequences for both donor harmonisation as well as equity of
funding across different provinces. Numerous examples already
exist from northeastern provinces where claims are being made
that insecure provinces in the south are benefiting through increasing
aid, as compared to the relatively stable north where the perception
is of reductions in aid funding.
October 2007
104 As reflected in the WHO constitution (1946),
Alma Ata Declaration (1976) and World Health Assembly (1998). Back
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